NSIPA Application for CIPA 2019-2020

Contact Information

Full Name
Street Address
City
State
ZIP Code
Preferred Phone Number
Fax
Email
Name as you would like it to appear on the certificate
If member of Region Auditor Association, pick one
If member of Local Auditor Association, enter here

References

Please list three verifiable references who are familiar with your premium audit experience. At least two of the references must be from the insurance premium audit industry.
Reference 1
Name
Title
Company
Mailing Address
Email Address
Reference 2
Name
Title
Company
Mailing Address
Email Address
Reference 3
Name
Title
Company
Mailing Address
Email Address

Employment History

Please list at least three years of employment history.
Current Employer
Name of Current Employer
Address
City
State
ZIP Code
Position
Dates of Employment
Supervisor Name
Phone Number
Email
Home Office Audit Manager Name
Phone Number
Email
Division Officer/Manager Name
Phone Number
Email
Previous Employer
Name of Previous Employer
Address
City
State
ZIP Code
Position
Dates of Employment
Supervisor Name
Phone Number
Email
Please provide how you qualify for three (3) years' experience in premium audits

Education Requirement

Candidates must pass APA 91, APA 92, CPCU 520 and two of the following three – CPCU 552, CPCU 540 or CPCU 557.
Candidates currently taking course CPCU 551 (Property Risk Management) will be allowed to continue as long as this course is taken and passed prior to January 1, 2016. As of January 2016, this course will no longer be considered part of the CIPA education requirement.
Your transcript must accompany your application. Therefore, you may email to nsipa@nsipa.org, fax it to (614)407-9595, or mail it to NSIPA, PO Box 936, Columbus, OH 43216.
I will send the transcript via

NSIPA Code of professional Ethics

"As a premium auditor, I will...
...be prudent in the use of information acquired in the course of my duties.
...provide a high standard of professional service to all policyholders.
...strive to improve my professional knowledge, skills and competence.
...perform my duties in a dignified and professional manner.
...not enter into any activity which is or may appear to be in conflict with the interest of my employer.
...not injure the professional reputation or practice of another premium auditor.
...cooperate in exchanging non-confidential information and experience with other premium auditors."
Sign the ethics agreement with your initials here:

Certify

I certify that the information on this application is correct and I agree to abide by the NSIPA Code of Professional Ethics, any amendments thereto, and to other requirements established by the NSIPA Board of Directors.
Select One

Payment

There is a one-time application fee of $50 for a NSIPA Member, $50 for a New NSIPA Member, and $125 for Non-Member. Applicants may join NSIPA online as a New Member at the time of submitting this application to get the member rate. Credit card or check is accepted.
Amount Due