Form CE/PL-200 "Instructor Approval Application - Continuing Education/Pre-licensing Program" - Kentucky

What Is Form CE/PL-200?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2010;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form CE/PL-200 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form CE/PL-200 "Instructor Approval Application - Continuing Education/Pre-licensing Program" - Kentucky

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CE/PL-200 (3-2010)
Kentucky Department of Insurance
Continuing Education/Pre-Licensing Program
Instructor Approval Application
 Continuing Education Instructor
 Pre-Licensing Instructor
P
I
ROVIDER
NFORMATION
Provider Name
Provider Number
I certify that the information on this form is true and correct to the best of my knowledge. It accurately represents
at least the minimum qualifications required to be met by the individual named on this form as an instructor.
Further, the individual named as an instructor has been approved by this Provider.
Print/Type Name of Provider Representative
Signature
Date
Title
I
I
NSTRUCTOR
NFORMATION
Instructor Last Name
First Name
Middle Name
Instructor Number
(Leave Blank)
 Yes
 No
Have you been known by any other names?
Social Security Number
If yes, list names:
-
-
Home Street Address
City
State
ZIP
Business Phone
(
)
ext.
List professional designations, insurance license (type, date, state):
I have specialized experience in the following subject matter:
Subject Matter
Years Experience
Designated Degree
_______________________________________
_________________
____________________________
_________________
____________________________
_______________________________________
_______________________________________
_________________
____________________________
I certify that the information on this form is true and correct to the best of my knowledge and the information
accurately represents my qualifications to teach insurance courses. I understand the information on this form is
subject to verification through the audit process. I agree to abide by all Kentucky statutes, regulations, and
program requirements regarding insurance and insurance continuing education and pre-licensing education.
Print/Type Name of Instructor
Signature
Date
P
P
T
. P
N
.
LEASE
RINT OR
YPE
HOTOCOPY AS
EEDED
Return this original completed form with any attachments to:
Prometric, 1260 Energy Lane, St. Paul, MN 55108
Send a copy of this form (no attachments) with instructor filing fees ($5.00 pre-licensing, $5.00 continuing education)
and form KYF-01 to: Kentucky Department of Insurance, P. O. Box 517, Frankfort, KY 40602-0517
CE/PL-200 (3-2010)
Kentucky Department of Insurance
Continuing Education/Pre-Licensing Program
Instructor Approval Application
 Continuing Education Instructor
 Pre-Licensing Instructor
P
I
ROVIDER
NFORMATION
Provider Name
Provider Number
I certify that the information on this form is true and correct to the best of my knowledge. It accurately represents
at least the minimum qualifications required to be met by the individual named on this form as an instructor.
Further, the individual named as an instructor has been approved by this Provider.
Print/Type Name of Provider Representative
Signature
Date
Title
I
I
NSTRUCTOR
NFORMATION
Instructor Last Name
First Name
Middle Name
Instructor Number
(Leave Blank)
 Yes
 No
Have you been known by any other names?
Social Security Number
If yes, list names:
-
-
Home Street Address
City
State
ZIP
Business Phone
(
)
ext.
List professional designations, insurance license (type, date, state):
I have specialized experience in the following subject matter:
Subject Matter
Years Experience
Designated Degree
_______________________________________
_________________
____________________________
_________________
____________________________
_______________________________________
_______________________________________
_________________
____________________________
I certify that the information on this form is true and correct to the best of my knowledge and the information
accurately represents my qualifications to teach insurance courses. I understand the information on this form is
subject to verification through the audit process. I agree to abide by all Kentucky statutes, regulations, and
program requirements regarding insurance and insurance continuing education and pre-licensing education.
Print/Type Name of Instructor
Signature
Date
P
P
T
. P
N
.
LEASE
RINT OR
YPE
HOTOCOPY AS
EEDED
Return this original completed form with any attachments to:
Prometric, 1260 Energy Lane, St. Paul, MN 55108
Send a copy of this form (no attachments) with instructor filing fees ($5.00 pre-licensing, $5.00 continuing education)
and form KYF-01 to: Kentucky Department of Insurance, P. O. Box 517, Frankfort, KY 40602-0517