Pg.1/2
FIN 517 | 0720
Apply for a continuing education exemption or extension
______
________________________________________________________________________ ____________________________
Licensee name License Number
_______________________________________________________________________ __________________________
Email Last 4 digits of SSN
I want to apply for a Permanent Exemption from continuing education:
(Excluding Title or Escrow Officer licensees)
I hereby certify that I have been licensed by the Texas Department of Insurance for
at least 20 continuous years with no gaps in licensure greater than 90 days, while
maintaining CE compliance for all CE terms.
*Please confirm your CE compliance by reviewing your Online CE Transcript found online at
www.sircon.com/texas
I want to apply for a CE Extension or waiver:
Check one box.
Illness or medical disability
Active military duty in a combat theater
Circumstance beyond the licensee’s control
Send all information that applies:
Medical illness or disability:
Medical evidence on a Physician and/or Hospital System letterhead regarding exact nature of illness
or disability that has prevented the licensee from completing the required hours within the two-year
reporting period.
A statement listing the activities of an agent or adjuster that the licensee can’t/couldn’t do as a
result of the condition or circumstances.
Estimated date the licensee will be able to perform activities of an agent or adjuster in accordance
with the medical reports or other documents.
Active military duty in a combat theater:
Copy of an order to active duty, expected duration of assignment, and any other information about
active military duty.
Texas Department of Insurance 2/2
Circumstance beyond the licensee’s control:
A written statement with the exact nature of the extenuating circumstance that prevented
or will prevent the licensee from completing the required hours within the two-year
reporting period. Business reasons do not constitute circumstances beyond the control of
the licensee.
Death of a family member: Copy of a Death Certificate or Obituary
Medical caretaker:
o A letter from the attending physician that states the licensee is the main caretaker.
o Medical evidence showing duration of illness that prevented the licensee from
completing the required hours within the two-year reporting period.
► Return this form and all attachments to CE@tdi.texas.gov.
Review is completed in time and date order.
Refer general questions to: (512) 676-6500
NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES:
With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you. Under
sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private
information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas
Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the
procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel
Section of TDI’s General Counsel Division at (512) 676-6551 or visit the Corrections Procedure section of TDI’s website at www.tdi.texas.gov.
Sign here:
Licensee signature: __________________________________________________________ Date: _________________
click to sign
signature
click to edit