*****  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.

 

 

 

This Affidavit should be used by examinees seeking insurance continuing education credits in Montana.

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 Title      
Location of examination Completion date

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 MT 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. An employee is much more likely to be pressured to falsify an affidavit, as is evidenced by the securities action against State Farm on this issue.

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
 

Updated 5-16-11

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.