IOWA INSURANCE DIVISION

Continuing Education

Affidavit of Personal Responsibility

TO BE SIGNED BY STUDENT

SEND TO: THE NATIONAL UNDERWRITER COMPANY

4157 OLYMPIC BLVD, SUITE 225, ERLANGER, KY 41018

(EMAIL TO: NucoCertificates@alm.com)

(Please note that this digital form will be automatically submitted to the above upon completion)

I declare that I personally completed this course without any outside assistance including course material, other source material or assistance from any person(s).

Student Signature: *

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Date: * +

Affidavit of Exam Completion

TO BE COMPLETED AND SIGNED BY EXAM MONITOR

I declare that I personally observed the above named individual during the completion of this examination and also observed that the producer received no outside assistance in completing the examination.

Name of Student: *

Name of Course: *

Address Where Course Was Taken: *

Date Exam Was Taken: * +

Beginning Time: *

Ending Time: *

Provider Number:

10060

Type of Monitor (check one): *

Provider Representative

Disinterested Third Party

Name of Person Administering Test: *

Job Title of Person Administering Test: *

Company/Agency Name: *

Business Phone Number: *

Business Mailing Address: *

Signature of Course Approved Monitor/CE Provider Representative: *

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Date: * +