Licensing Division
50 W. Town St., 3rd Fl.
Suite 300
Columbus, Ohio 43215
(614) 644-2665
Fax # (614) 387-0051
www.ohioinsurance.gov
Ohio Department of Insurance
John R. Kasich – Governor
Mary Taylor – Lt. Governor/Director
PRE-LICENSING SELF-STUDY COURSE
AFFIDAVIT
AFFIDAVIT OF PERSONAL RESPONSIBILITY
(To be completed and signed by student)
I declare that I personally completed this exam without any outside assistance including course material, other source material or
assistance from any person(s).
Name (Print)
Signature (sign in ink only)
Date
SSN (Last 4 Digits)
Telephone Number
AFFIDAVIT OF EXAM COMPLETION
(To be completed and signed by exam monitor)
I declare that I am a disinterested third party and that the above individual completed this exam without any outside assistance
including course material or assistance from any person(s) including myself.
Proctor Name (Print)
Signature (sign in ink only)
Date
Telephone Number
Type of monitor (check one)
Provider Representative
Test Administration Service
Other Disinterested 3rd
Exam Type (check one)
Life
Accident & Health
Personal Lines
Party
Date Exam Taken
Beginning Time
Property
Casualty
Surety Bail Bond
Ending Time
A.D. Banker & Company, L.L.C.
Provider Name (Print)
Provider ID
Exam Location Address
Accredited by the National Association of Insurance Commissioners (NAIC)
INS3273 (Rev. 01/2011)
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