5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 1 ORIGINAL INSURANCE APPLICATION FOR RESIDENT OR NON-RESIDENT INSURANCE LICENSE (INDIVIDUAL) 1. LICENSE TYPE: Check box that applies for each category. Applicant must complete a separate application for each license type. a)  Resident  Non-Resident b) Agent Broker Independent-Adjuster Public-Adjuster Solicitor Surplus Line Broker (residents only) General Agent (residents only) General Manager (residents only) c) Life  Health Property  Casualty Title Annuities Disability Surety Variable Annuities Variable Contracts Variable Life 2. NAME OF APPLICANT: Mr. Mrs. Ms. Last First Middle Name: 3. IDENTIFICATION INFORMATION: S.S.N. Sex: M F Date of Birth: Place of Birth: MM/DD/YYYY City, State 4. BUSINESS ADDRESS: (P.O. Box not acceptable) Address Change from last renewal? Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Business Phone No: ( ) - ________ - _____________ Fax Phone No: ( ) - ______ - ______________ Email: Website: 5. RESIDENCE ADDRESS: (P.O. Box not acceptable) Address Change from last renewal? Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Home Phone No: ( ) - _________ - _________________ 6. MAILING ADDRESS: Business Residence Address Change from last renewal? Street/P.O. Box _____________________________________ Apt/Suite # ___________________________ City _________________________________ State _______________________ Zip Code ______________ 7. Do you intend to use a fictitious (DBA) name to transact insurance business? Yes No If yes, please list name _____________________________________________________________________________ 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 2 8. Are you now or have you ever used any name other than shown in (2) or (7)? Yes No If yes, list names, dates, and reasons used. Name Date Reason 9. RESIDENT OR NON-RESIDENT LIFE AGENT APPLICANTS ONLY:  N/A a) If you intend to act as a Variable Contract Agent, are you registered with the Division of Banking and Insurance? Yes No (If yes, provide your BD-A registration number. If no, state the reason why you have not registered.) b) If you intend to act as a Variable Contract Agent, are you registered with NASD? Yes No (Provide evidence of same. 10. GENERAL AGENT OR GENERAL MANAGER APPLICANTS (residents only):  N/A List the names of the authorized companies which you will represent and from which you have received an appointment. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) 11. RESIDENT OR NON-RESIDENT AGENT APPLICANTS:  N/A a) List names of the authorized companies licensed in the Virgin Islands through which you will represent and from which you have received an appointment. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 3 b) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated _______________________________________________________________________________________ 12. RESIDENT OR NON-RESIDENT BROKER APPLICANTS:  N/A a) List names of authorized companies through which business will be placed. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) b) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated. _______________________________________________________________________________________ c) Broker Bond Number _____________________________ Expiration Date __________________ Surety Company _______________________________ 13. SOLICITOR APPLICANTS:  N/A Provide the name of the Agent and/or Agency with which you are appointed. 14. SURPLUS LINE BROKER APPLICANTS ONLY:  N/A a) List the names of all “unauthorized insurers” or “surplus lines carries” that are eligible to conduct surplus lines business in the Virgin Islands with which arrangements have been made to accept or which are considering the acceptance of surplus lines business offered by applicant: (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) Eligible Unauthorized Insurers in the Virgin Islands b) Broker Bond Number ___________________________ Expiration Date _________________________ Surety Company _________________________________ 15. RESIDENT ADJUSTER APPLICANTS ONLY:  N/A 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 4 If you are an Office Manager, list names of adjusters working directly under your supervision: 16. RESIDENT OR NON-RESIDENT INDEPENDENT ADJUSTER APPLICANTS:  N/A List Companies with which you are affiliated: 17. RESIDENT OR NON-RESIDENT PUBLIC ADJUSTER APPLICANTS:  N/A Public Adjuster Bond Number: Surety Company: 18. ALL APPLICANTS: If you hold or have ever held an insurance license, complete the following:  N/A Type of License State Resident Nonresident Date License Held From To 19. ALL APPLICANTS: List your places of residents for the past five years. From (MM/YYYY) To (MM/ YYYY) Street City State Postal Code 20. ALL APPLICANTS: List your occupation (employment) for the past five years to current: From (MM/YYYY) To (MM/YYYY) Employer Name Address Duties Performed 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 5 21. a) Have you ever had any professional, vocational or business license denied, suspended, revoked or restricted or a fine imposed by any Public Authority, or withdrawn any application for or surrendered any such license to avoid disciplinary action? Yes No (If yes, please explain fully on a separate sheet) b) Are there currently any disciplinary actions pending against you? Yes No (If yes, please explain fully on a separate sheet) 22. Have you ever been arrested, charged or conviction of a crime? Yes No If yes, attach a detailed statement, signed by you, of the events which led to the charges including the dates and places. If the matter was heard in court, attach copies Certified by the Court, of the Criminal Complaint and the Sentencing Order showing the final judgment.) 23. Have you been indebted, other than current accounts, to any insurance company or person for unpaid insurance premiums or return premiums? Yes No (If yes, please explain fully on a separate sheet) 24. Have you, the past ten years, ever been involved any bankruptcy or receivership proceedings? Yes No (If yes, please explain fully on a separate sheet) IMPORTANT NOTICES: Failure to fully answer all questions on application and non-submission of the required documents will result in the application being returned to applicant. Additionally, applicant must promptly notify the Division of Banking and Insurance of any changes in the information reported on this application including, but not limited to, the information reported in questions (21), (22), (23), and (24) any changes in the business operations of the Applicant. If the answer is "YES" to questions (21), (22), (23), and (24) attach a notarized statement detailing the events which led to the charges, claim or complaint including the dates and jurisdiction in which the charges, claim or complaint was filed. If the matter was heard in a court, attach copies, CERTIFIED BY THE COURT, of the Claim or Criminal Complaint and the final order or judgment. If the matter was heard by an administrative agency, attach copies of the claim or complaint and a document evidencing final disposition of the matter. APPLICANT’S CERTIFICATION: I certify under penalty of perjury that I have read the foregoing application and know the contents thereof and that each statement therein made is true and correct. I understand that any false statement may subject my application to denial and may subject my license(s) to suspension or revocation. Further, I authorize disclosure to the insurance commissioner of all financial institutions’ records of any fiduciary accounts for the duration of this license. Date _______________________ ______________________________________ Signature ________________________________________ Print Name 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 6 The following items are needed for licensure: Identification (Gov’t issued, i.e.: Driver’s license, Passport, Voter’s Registration Card, etc. ------------------ Tax Clearance Letter ----------------------------------------- License or Letter of Certification from State of domicile Broker’s Bond -------------------------------------------------- Surplus Lines’ Bond -------------------------------------------- Public Adjuster’s Bond ---------------------------------------- Three Letters of Recommendation---------------------------- Written Examination------------------------------------------- Original License Fee-------------------------------------------- Appointment Forms & Fee------------------------------------- Resident & Non-resident Resident only Non-resident only Resident & Non-resident Resident only Resident & Non-resident Resident only Resident only Resident & Non-resident Resident & Non-resident RESIDENT ORIGINAL FEE BOND Solicitor $300.00 N/A Agent $300.00 N/A Appointment Fee (Agent/Solicitor) $ 25.00 N/A General Agent $600.00 N/A Resident Broker $400.00 10,000.00 Surplus Line Broker $400.00 10,000.00 Adjuster (Independent/Public) $300.00 5,000.00 (Public Only) NON-RESIDENT ORIGINAL FEE BOND Agent $600.00 N/A Broker $800.00 10,000.00 Adjuster (independent/Public) $300.00 5,000.00 (Public Only) Appointment Fee (Agents) $ 25.00 N/A All checks and money orders must be made payable to Government of the U.S. Virgin Islands. FOR OFFICE USE ONLY Receipt Number: _______________________ Date: __________________ Amount: $_________________ (REV: 09/2013) 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 7 Government of the United States Virgin Islands Office of the Commissioner – Division of Banking and Insurance #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 TEL-340-774-7166 FAX 340-774-5590 Appointment of Agent Pursuant to Title 22, Section 753, of the Virgin Islands code, the undersigned insurance company hereby applies for authorization for: _________________________________________________________________ (Name of Agent/Agency) ________________________________________________________________ (Business Address of Agent/Agency. Post Office Box not accepted) _________________________________________________________________ (Kinds of Insurance Agent/Agency will write) The above agent is hereby authorized to solicit, accept applications, write, issue, deliver and place policies or contracts of direct insurance upon risks located within the Virgin Islands, effective ___________ 20___ and expiring on ___________ 20___. ________________________________________________________________________ (Please print full legal name of Insurance Company) ________________________________________________________________________ (To be signed by an authorized signatory designated to appoint and/or terminate agents in the United States Virgin Islands) ________________________________________________________________________ (Print Name) _________________________________________________________________ (DO NOT WRITE BELOW THIS LINE) This document is hereby approved and filed in the Office of the Commissioner of Insurance, ____________________________________ ___________________ Commissioner of Insurance Date 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 Page 8 STATEMENT OF AGREEMENT TO SERVE AS INSURANCE AGENT Pursuant to Title 22, Section 753, of the Virgin Islands Code, I hereby agree to serve as agent for_____________________________________________________of (Please print full legal name of Insurance Company) _________________________________________ in and for the Virgin Islands of the (Company’s State of Domicile address) United States, and further agree that I will not rebate any part of the premium or commission or offer any valuable consideration as an inducement to take insurance other than that clearly expressed in the policy. Further, I shall keep at my address as shown on my license, during all business hours a complete record of all transactions to include applications for and policies of insurance placed by or through me pursuant to Title 22, Section 784, of the Virgin Islands Code, and will not sign any policies in blank to be issued outside my office. _______________________________________ Signature of Agent/Agency’s Authorized Signatory _______________________________________________________________________ Subscribed and sworn to before me this __________day of ____________________, 20___________at________________________________________________________ ____________________________________________ (Notary Public)