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INDIANA DEPARTMENT OF INSURANCE
AFFIDAVIT OF PERSONAL RESPONSIBILITY


Instructions to Course Provider: This Affidavit does not replace Certificate of Completion. The original Affidavit is to be returned to you with finished examination and must be retained in your files for four (4) years.

I affirm, under penalties of perjury, that I personally completed the entire text of the self-study course listed below. I also affirm, under penalties of perjury, that I completed the exam without assistance from any source. I understand that this a closed book examination and I may not refer to the study material for answers. I also understand that it is my responsibility to file or maintain my Certificate of Completion as required by the Indiana Department of Insurance.
 

Agents Signature
(You can sign this form by typing in your name)		 Date Agents License Number

AFFIDAVIT OF EXAM COMPLETION


I hereby certify, under penalty of perjury, that I am a duly licensed insurance agent in the State of Indiana or I am an employee of and that I administered the closed book final examination for the course listed below and that it was completed without assistance or outside help of any kind, including the study material.
 
Name of Student:
Name of Course:
Name of Course Provider: Broker Educational Sales & Training, Inc.
Location Exam Was Taken:
Date Exam Was Taken:

 

Printed Name of Exam Witness Signature of Exam Witness
(You can sign this form by typing in your name)
License Number of Witness Business Phone Number of Witness
Witness Business Mailing Address
City, State Zip 

 

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

If you are printing this affidavit to send to Broker Educational Sales & Training, Inc. then send to:
Broker Educational Sales & Training, Inc.
7137 Congress Street
New Port Richey, FL 34653
or fax to: 727-372-7585
or email to: processing@brokered.net

By pressing the Submit button below you are electronically sending this form to us.