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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.
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.

 

 

Disinterested Third Party - Monitor/Proctor Form

(To be used by examinees seeking insurance continuing education credits in AL, CO, DC, GA, HI, ME, MI, NV, OH, RI, & WY)


* Form to be filled and signed by both examinee and disinterested third party. The disinterested third party must fill in time examinee began with exam and the time examinee ended with exam *

 

This section is to be completed by Examinee:

 
Name Business/Daytime Phone  
Business/Daytime Address City State Zip
 
State of licensure License number  

I certify that I completed this examination without the outside assistance of any person. I certify that I used no outside materials or course materials in completing this exam.

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

This section is to be completed by Disinterested Third Party - Monitor/Proctor:

   
Name     Relationship to Examinee
Business/Daytime Address City State Zip
 
Business/Daytime Phone   Insurance license number, if any State of licensure
     
Course Title      
Location of examination Completion date

I certify that I verified the identification of the examinee who signed above, and that the examinee completed this examination without the outside assistance of any person. I certify that the examinee used no outside materials or course materials in completing this exam.

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

Updated 3/22/2023

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.