Form CPL-01 "Certificate of Pre-licensing Course Completion" - Kentucky

What Is Form CPL-01?

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 August 1, 2019;
  • 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;
  • Fill out the form in our online filing application.

Download a printable version of Form CPL-01 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form CPL-01 "Certificate of Pre-licensing Course Completion" - Kentucky

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FORM CPL-01
(Rev. 8-2019)
COMMONWEALTH OF KENTUCKY
DEPARTMENT OF INSURANCE
P. O. Box 517
Frankfort, Kentucky 40602-0517
502-564-6004
http://insurance.ky.gov
CERTIFICATE OF PRE-LICENSING COURSE COMPLETION
This form must be completed in its entirety and furnished to each attendee satisfactorily completing,
(Check One)
 forty (40) hours for two-lines of authority or  twenty (20) hours for one-line of authority
of training as the educational requirement prescribed by KRS 304.9-105. The pre-licensing program must
be in compliance with the plan filed and approved by the Kentucky Department of Insurance. This
certificate must be submitted to the Kentucky Department of Insurance with an application for insurance
license, KY Administrative Office of the Courts (AOC) criminal background report, and applicable fees,
before a notice for examination will be issued.
Student Name:
SS#
Resident Address:
Course Conducted By:
Education Provider Name and ID #:
Course Name and ID #:_____________________________________________________
Instructor Name (if applicable):_______________________________________________
* Course Completion Date:__________________________________________________
EDUCATION PROVIDER CERTIFICATION
I hereby certify that this individual has successfully completed this pre-licensing training
course in its entirety, and that the course was conducted in accordance with the outline
approved by the KY Department of Insurance.
Authorized Signature:
Date:
STUDENT CERTIFICATION
I hereby certify that I have personally completed the above-named course in its entirety in
order to be compliant with Kentucky Insurance Laws and Regulations.
Student’s Signature:
Date:
* THIS CERTIFICATE IS VALID ONE YEAR FROM DATE OF COMPLETION *
FORM CPL-01
(Rev. 8-2019)
COMMONWEALTH OF KENTUCKY
DEPARTMENT OF INSURANCE
P. O. Box 517
Frankfort, Kentucky 40602-0517
502-564-6004
http://insurance.ky.gov
CERTIFICATE OF PRE-LICENSING COURSE COMPLETION
This form must be completed in its entirety and furnished to each attendee satisfactorily completing,
(Check One)
 forty (40) hours for two-lines of authority or  twenty (20) hours for one-line of authority
of training as the educational requirement prescribed by KRS 304.9-105. The pre-licensing program must
be in compliance with the plan filed and approved by the Kentucky Department of Insurance. This
certificate must be submitted to the Kentucky Department of Insurance with an application for insurance
license, KY Administrative Office of the Courts (AOC) criminal background report, and applicable fees,
before a notice for examination will be issued.
Student Name:
SS#
Resident Address:
Course Conducted By:
Education Provider Name and ID #:
Course Name and ID #:_____________________________________________________
Instructor Name (if applicable):_______________________________________________
* Course Completion Date:__________________________________________________
EDUCATION PROVIDER CERTIFICATION
I hereby certify that this individual has successfully completed this pre-licensing training
course in its entirety, and that the course was conducted in accordance with the outline
approved by the KY Department of Insurance.
Authorized Signature:
Date:
STUDENT CERTIFICATION
I hereby certify that I have personally completed the above-named course in its entirety in
order to be compliant with Kentucky Insurance Laws and Regulations.
Student’s Signature:
Date:
* THIS CERTIFICATE IS VALID ONE YEAR FROM DATE OF COMPLETION *