Form CE/AFF-304 Affidavit for Exemption From Continuing Education - Kentucky

Form CE/AFF-304 or the "Affidavit For Exemption From Continuing Education" is a form issued by the Kentucky Department of Insurance.

Download a PDF version of the Form CE/AFF-304 down below or find it on the Kentucky Department of Insurance Forms website.

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Commonwealth of Kentucky
DOI
Department of Insurance
Form CE/AFF-304
Rev. 3-2010
Agent Licensing Division
P. O. Box 517, Frankfort, KY 40602-0517
502-564-6004
http://insurance.ky.gov
AFFIDAVIT FOR EXEMPTION FROM CONTINUING EDUCATION
Comes the Affiant,
, after having been first duly
(Please Type or Print Licensee Name)
sworn, and pursuant to KRS 523.020 (Perjury in the Second Degree) states as follows:
Affiant holds an agent license issued by the Kentucky Department of Insurance.
Affiant is eligible for the exemption set forth in KRS 304.9-295 from the requirement that Affiant
complete a minimum of 24 hours of continuing education each compliance date to maintain the agent
license.
Affiant is maintaining the agent license for the sole purpose of receiving renewals or deferred
commissions for business written on or prior to Affiant’s date of retirement or last activity on:
.
(Date)
Affiant acknowledges that use of this affidavit for any other reason, including an extension for
completion of continuing education requirements for a continuing education compliance date, shall be a
violation of KRS 304.9-295 and shall subject the Affiant to suspension or revocation of the agent license.
Affiant acknowledges that, as long as this Affidavit is in effect, Affiant may not engage in any
activity that constitutes conducting the business of insurance, which includes selling, soliciting,
advertising, explaining coverage, quoting rates, taking applications, writing business, and accepting
premiums. Affiant acknowledges that he/she must maintain active status of the license by maintaining
all additional requirements, or the Affidavit will become null and void.
(AGENT SIGNATURE)
(DATE SIGNED)
(ADDRESS)
(KY DOI #)
STATE OF KENTUCKY
COUNTY OF:
Subscribed, sworn to, and acknowledged before me by
to be the Affiant’s own free act and deed this
day of
,
.
Notary Public, State at Large:
My Commission Expires:
NOTE: It is a Class A misdemeanor to make a material false statement in a written sworn instrument with the intent to mislead a public servant in the performance
of his or her official duties.
Commonwealth of Kentucky
DOI
Department of Insurance
Form CE/AFF-304
Rev. 3-2010
Agent Licensing Division
P. O. Box 517, Frankfort, KY 40602-0517
502-564-6004
http://insurance.ky.gov
AFFIDAVIT FOR EXEMPTION FROM CONTINUING EDUCATION
Comes the Affiant,
, after having been first duly
(Please Type or Print Licensee Name)
sworn, and pursuant to KRS 523.020 (Perjury in the Second Degree) states as follows:
Affiant holds an agent license issued by the Kentucky Department of Insurance.
Affiant is eligible for the exemption set forth in KRS 304.9-295 from the requirement that Affiant
complete a minimum of 24 hours of continuing education each compliance date to maintain the agent
license.
Affiant is maintaining the agent license for the sole purpose of receiving renewals or deferred
commissions for business written on or prior to Affiant’s date of retirement or last activity on:
.
(Date)
Affiant acknowledges that use of this affidavit for any other reason, including an extension for
completion of continuing education requirements for a continuing education compliance date, shall be a
violation of KRS 304.9-295 and shall subject the Affiant to suspension or revocation of the agent license.
Affiant acknowledges that, as long as this Affidavit is in effect, Affiant may not engage in any
activity that constitutes conducting the business of insurance, which includes selling, soliciting,
advertising, explaining coverage, quoting rates, taking applications, writing business, and accepting
premiums. Affiant acknowledges that he/she must maintain active status of the license by maintaining
all additional requirements, or the Affidavit will become null and void.
(AGENT SIGNATURE)
(DATE SIGNED)
(ADDRESS)
(KY DOI #)
STATE OF KENTUCKY
COUNTY OF:
Subscribed, sworn to, and acknowledged before me by
to be the Affiant’s own free act and deed this
day of
,
.
Notary Public, State at Large:
My Commission Expires:
NOTE: It is a Class A misdemeanor to make a material false statement in a written sworn instrument with the intent to mislead a public servant in the performance
of his or her official duties.

Download Form CE/AFF-304 Affidavit for Exemption From Continuing Education - Kentucky

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