Please provide the following contact information:

Last 5 digits of SS #	NPN      Get Your NPN
Name as it appears on your insurance license.
Name of Person Paying if Other than Yourself:
Address
City
State	NC SC VA
Zip Code
Home Phone
Work Phone
Cell Phone
Fax Number
E-mail
Agency Affiliation

Please check the courses you wish to take:

Courses

Course Title		Course Hours
	Friday Feb 17 (6:30 p.m.- 9:20 p.m.) C72710 The Insurance Agent’s Guide to HIPAA	3 ($27.00)
	Saturday Feb 18 (8:00 a.m. - 2:50 p.m.) C71181 Compliance and Ethics	6 ($54.00)
	Saturday Feb 18 (3:00 p.m.-5:50 p.m.) C72711 The Insurance Agent’s Guide to COBRA	3 ($27.00)

 Comments

Refund, Check, and No Show Policy There will be a $25.00 returned check charge on all checks returned. Any refunds will be subject to a 10% administrative fee deducted from the return. There will be no refunds on self-study courses - no refunds on books, computer programs, or other material purchased. All courses begin the time the self-study material is received.  The student is responsible for the fees unless other arrangements have been made and approved by the school.

Payment Method Select credit card cashiers check money order cash

Once you submit this form you will be directed to our payment options.   If you wish to pay by credit card, you will be directed to our online course catalog.  If you choose to pay by cashier's check, money order, or cash you will receive a link to our course catalog via email. All of our credit card payments are processed securely through