TERRITORY OF THE UNITED STATES VIRGIN ISLANDS
OFFICE OF THE LIEUTENANT GOVERNOR
DIVISION OF BANKING AND INSURANCE
**************
APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY
1.
Name of Company ___________________________________________________
(Please indicate company’s full legal name)
Physical Address ____________________________________________________
____________________________________________________
Mailing Address: ____________________________________________________
____________________________________________________
Telephone No. ____________________________ Fax No. __________________
2. Company’s FEIN Number ______________________________________________
3. Type of Company: □Domestic □Foreign □Alien
4. Lines of Insurance: □ Life □Health □Property □Casualty □ Title □ All Lines
□ Other _________________________
5.
Contact Person for Premium Tax Quarterly Filings
Name/Title: _________________________________________________________
Mailing Address: ____________________________________________________
______________________________________________________
Telephone No. ___________________________Fax No._____________________
E-Mail _____________________________________________________________
6.
Contact Person for Annual Statement and Audited Financial Report Filing
Name/Title: _________________________________________________________
Mailing Address: ____________________________________________________
_____________________________________________________
Telephone No.________________________ Fax No.________________________
E-Mail_____________________________________________________________
Office of the Lt. Governor Division of Banking & Insurance Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802
Phone (340) -774-7166 Fax (340)-774-9458
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7.
Contact Person for Licensure and related filings
Name/Title: _________________________________________________________
Mailing Address: _____________________________________________________
______________________________________________________
Telephone No. ________________________Fax No._________________________
E-Mail______________________________________________________________
8.
Contact Person for Policy Forms
Name/Title: __________________________________________________________
Mailing Address: ______________________________________________________
_______________________________________________________
Telephone No. ________________________ Fax No.________________________
E-Mail______________________________________________________________
9. Contact Person for Consumer Complaints
Name/Title: __________________________________________________________
Mailing Address: ______________________________________________________
_______________________________________________________
Telephone No. __________________________Fax No._______________________
E-Mail:______________________________________________________________
10. Contact Person – Company’s Statutory Deposit
Name/Title: __________________________________________________________
Mailing Address:______________________________________________________
_______________________________________________________
Telephone No. ___________________________Fax No.______________________
E-Mail______________________________________________________________
Office of the Lt. Governor Division of Banking & Insurance Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802
Phone (340) -774-7166 Fax (340)-774-9458
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11. Authorized Signatory to Appoint and Terminate Agents in the U.S. Virgin Islands
Name (Print)
Signature
________________________________
______________________________
________________________________
______________________________
________________________________
______________________________
12. List Name of Agent(s)/Agency currently representing Company in the U.S. Virgin
Islands for marketing of products
________________________________
_________________________________
________________________________
_________________________________
________________________________
_________________________________
13. General Agent resident in the U.S. Virgin Islands to appoint subagents
________________________________
_________________________________
________________________________
_________________________________
14. Contact Person for company’s participation in V.I. Guaranty Fund (if applicable)
Name/Title:___________________________________________________________
Mailing Address:_______________________________________________________
______________________________________________________
Telephone No. ___________________________ Fax No.______________________
E-Mail:______________________________________________________________
Office of the Lt. Governor Division of Banking & Insurance Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802
Phone (340) -774-7166 Fax (340)-774-9458
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IMPORTANT NOTICE: The company must promptly notify the Division of
Banking and Insurance of any changes in the information reported on this
application.
PERSON COMPLETING THIS APPLICATION:
Name______________________________________ Date_____________________
(Please Print)
Signature ______________________________________________________________
Relationship to Company _________________________________________________