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leave this window open so the monitor can input the ending time of the exam.

Some affidavits request that you fill out and mail to Broker Educational Sales & Training, Inc.
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This Affidavit should be used by examinees seeking insurance continuing education credits in AL, CO, DC, GA, HI, ME, Ml, NJ, NV, OH, RI, & WY.
Examinees seeking insurance continuing education credits in AR, AZ, CT, FL, IA, IN, MA, MN, MO, MS, MT, NC, NE, NY, OR, PA, SC, VA, VT, WI,  & WV should use the State-specific Affidavit provided.

Disinterested Third Party/Monitor/Proctor Affidavit

This section to be completed by Disinterested Third Party/Monitor/Proctor. Please check your individual state requirements to determine if you qualify as a Disinterested Third Party/Monitor/Proctor in the applicable state.

   
Name     Relationship to Examinee
Business/Daytime Address City State Zip
Business/Daytime Phone Fax Insurance license held, if any State of licensure
   
Insurance license #, if any     Instructor # or Monitor #, if any
     
Course Tile      
Location of examination Completion date Time exam began Time exam ended

I certify that I verified the identification of the examinee who signed below, and that the examinee completed this examination without the outside assistance of any person. I certify that the examination was administered as a closed-book examination (except for AZ who may refer to the course material as often as needed), and the examinee used no outside materials or course materials in completing this exam. I certify that, to my knowledge, no copies of this examination were made. I certify that I meet the requirements of a Disinterested Third Party/Monitor/Proctor in the state for which this examinee seeks insurance continuing education. I certify that, for examinations for which credit is sought in AL, CO, DC, GA, HI, ME, Ml, NJ, NV, OH, RI, & WY the examination remained sealed until the time of testing. I further certify that for examinations for which credit is sought, I am not a relative, work supervisor, or immediate employer of the examinee.

Signature of Disinterested Third Party/Monitor/Proctor
(You can sign this form by typing in your name)
Date

 


This section to be completed by Examinee.

 
Name Business/Daytime Phone Fax  
Business/Daytime Address City State Zip
 
Insurance license held State of licensure License number  

I certify that I completed this examination without the outside assistance of any person. I certify that the examination was administered as a closed-book examination, if required, and that I used no outside materials or course materials in completing this exam. I certify that I did not make or retain copies of this examination. I certify that, upon completion of this examination, I immediately returned my exam booklet, answer sheet, and this Affidavit to the Disinterested Third Party/Monitor/Proctor.

Signature of Examinee
(You can sign this form by typing in your name)
Date

Please return Affidavit Form to BEST. Materials may be mailed to
Broker Educational Sales & Training, Inc., 7137 Congress Street, New Port Richey, FL 34653
or faxed to (727) 372-7585
or emailed to processing@brokered.net if needed.
 

Updated 7/11/2018

Before clicking Submit below
 
 Affidavit must be filled out completely for credit.
 Any missing information will delay credit to examinee.