IOWA AFFIDAVIT

Producer’s Declaration

I, ______________________________________(Print name) with an Iowa

insurance license number of: _________________, hereby declare that I
(Mandatory)
Personally completed this examination without any outside assistance. My

Monitor for this exam was _________________(Print name) and their Iowa

CE Provider number/insurance producer license number (strike thru one) is
__________.

______________________ ____________________
Signature Date

Monitor’s Declaration

I, _____________________ hereby declare that I personally observed

_______________________ during the completion of this examination and

also observed that the producer received no outside assistance in completing

the examination. My Iowa CE provider number/insurance producers license

number (strike thru one) is ____________________. This test was

monitored at __________________________________________________.
Address, City, State, Zip Code

______________________ ____________________
Signature Date

CONTINUING EDUCATION INSURANCE SCHOOL

This signed affidavit must be faxed to Myceisonline at 800-479-8700 immediately after taking your exam for processing. Print This Page