*****  This affidavit has opened in a new window  *****

Take a quick look at this affidavit. If the affidavit requires a beginning and ending time field
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.
By clicking the Submit button below the affidavit is being electronically sent to them.

You may want to print this page after filling out all the details as a record for yourself.

 

 

STATE OF MISSISSIPPI

AFFIDAVIT OF PERSONAL RESPONSIBILITY



I affirm that I personally completed the entire study material of the course. I also confirm that I completed the exam without assistance from any course material, other source material, or from any persons. I understand it is my responsibility to maintain my certificate of completion as required by the Mississippi Insurance Department

 

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

License Number

Printed Name of Student

Date

Daytime Phone Number

Email Address


AFFIDAVIT OF EXAM COMPLETION
To be completed and signed by Exam Monitor
(Please Print)


I certify that I verified the identification of the student. In addition, I personally observed the final examination and certify that it was complete without assistance or outside help of any kind.

 

Name of Student

Name of Course

Physical Address where exam was taken

Date of Examination

Beginning Time

Ending Time



Type of Monitor: Disinterested Third Party
A Disinterested 3rd Party is defined as a licensed insurance producer, independent adjuster or public adjuster or a person with no family or financial relationship to the student.

 

Print Name of the Monitor

Job title of the Monitor

Name of Monitor’s Employer

Business Phone Number

Business Mailing Address
 

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

Date

 

 

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.