bjbjìrìr Government of the Unites States Virgin Islands Office of the Commissioner – Division of Banking, Insurance and Financial Regulation #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 TEL-340-774-7166 FAX 340-774-5590 APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY CERTIFICATE OF LICENSURE or PERMIT (Please indicate Company’s full legal name) Organization Type: Contact Person for Annual Statement and Audited Financial Report Filing Contact Person for Licensure and related filings Contact Person for Policy Forms Contact Person for Consumer Complaints 10. Contact Person – Company’s Statutory Deposit 11. Authorized Signatory to Appoint and Terminate Agents in the U.S. Virgin Islands Print Name 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): IMPORTANT NOTICE: The Company must promptly notify the Division of Banking, Insurance and Financial Regulation of any changes in the information reported on this application. PERSON COMPLETING THIS APPLICATION: (Please Print) Signature h‰n( haT4 h‰n( h‰n( hÏJy hi/Ó h‰n( hÈs8 gd‰n( h‰n( hsW& haT4 h‰n( gdw@p gdaT4 gdaT4 hzpÆ hzpÆ hzpÆ hzpÆ hw@p h‰n( haT4 h‰n( hw@p haT4 hw@p hZr· hZr· hZr· hZr· hzpÆ hzpÆ gd‰n( gdaT4 gdaT4 gd‰n( gdw@p gdzpÆ h8C— haT4 h‰n( h‰n( hw@p hw@p hw@p hw@p hw@p h8C— hw@p hi/Ó haT4 h‰n( þgdaT4 gd‰n( gdaT4 hsW& hw@p h‰n( haT4 h8C— h‰n( gd8C— þgdD þgdaT4 þgdaT4 h8C— h‰n( hw@p gdêy5 gd‰n( þgdD gd8C— h‰n( hslè h8C— hi/Ó h8C— hw@p h‰n( h‰n( h‰n( h‰n( hsW& hi/Ó h‰n( h8C— hslè h‰n( hw@p gd8C— gdi/Ó hslè hsW& hÍQ' hÍQ' hsW& PAGE Office of the Lt. Governor (Division of Banking, Insurance and Financial Regulation Kongens Gade #5049(St. Thomas, U.S. Virgin Islands (00802 Phone (340) -774-7166 (Fax (340)-774-9458 PAGE \* MERGEFORMAT gdY@ gdsW& &`#$ gdmgù IHDR pHYs tEXtSoftware Adobe ImageReadyqÉe< d&÷T &r(ïv dZ ö4 v;ms¼& ",òx ƒ.Kc ‡s os ‡r owY 20PŽ Gj{L 'i-ª ìx;T v4¯oK IHDR sRGB pHYs tEXtSoftware ²IDAThCµz ùF;, &IA,”D"šDoW {u&j arò, õVRC 4w)((3‰¬ p1tHH£|M" Eø(8z "A5%« ;qªy 0:&cªg)tñ Ji;D J­x-6Jn^ Sqäp J0 ·4a $n|8•)UE TS;: gEÎ. 0L4a(vÑ »ŸmN4W0' ,;¹w:¯pe nÂhi ()7¢ -$O› #Y5÷I Ë5v& _rels/.rels„ÏjÃ0 theme/theme/themeManager.xml theme/theme/theme1.xmlìYKo A/ý1 k):b| DñZ. 6pp1GZ&àL~AdÒNP W÷c%WS wae& Ô2IQ 5oºi x%j.l)l theme/theme/_rels/themeManager.xml.rels„M g‘K(M&$R(.1 [Content_Types].xmlPK _rels/.relsPK theme/theme/themeManager.xmlPK theme/theme/theme1.xmlPK theme/theme/_rels/themeManager.xml.relsPK _rels/.rels¤ÁjÃ0 7Luò bÂf4g drs/e2oDoc.xmlìXÛnã6 GA8s¦g drs/_rels/e2oDoc.xml.rels„AjÃ0 0HcYÄ drs/downrev.xmlLAKÃ@ drs/media/image1.png‰PNG IHDR pHYs tEXtSoftware Adobe ImageReadyqÉe< d&÷T &r(ïv dZ ö4 v;ms¼& ",òx ƒ.Kc ‡s os ‡r owY 20PŽ Gj{L 'i-ª ìx;T v4¯oK [Content_Types].xmlPK _rels/.relsPK bÂf4g drs/e2oDoc.xmlPK drs/_rels/e2oDoc.xml.relsPK drs/downrev.xmlPK drs/media/image1.pngPK [Content_Types].xml|ÏNÃ0 _rels/.relslÏÁjÃ0 drs/downrev.xmlDOkÂ@ [Content_Types].xmlPK _rels/.relsPK drs/downrev.xmlPK [Content_Types].xml|ÏNÃ0 _rels/.relslÏÁjÃ0 drs/downrev.xmlDOKkÂ@ [Content_Types].xmlPK _rels/.relsPK drs/downrev.xmlPK [Content_Types].xml|ÏNÃ0 _rels/.relslÏÁjÃ0 drs/downrev.xmlDOoÂ0 [Content_Types].xmlPK _rels/.relsPK drs/downrev.xmlPK [Content_Types].xml|ÏNÃ0 _rels/.relslÏÁjÃ0 drs/downrev.xmlDOKkÂ@ [Content_Types].xmlPK _rels/.relsPK drs/downrev.xmlPK [Content_Types].xml|ÏNÃ0 _rels/.relslÏÁjÃ0 drs/downrev.xmlDOMkÂ@ Z½(h [Content_Types].xmlPK _rels/.relsPK drs/downrev.xmlPK urn:schemas-microsoft-com:office:smarttags country-region urn:schemas-microsoft-com:office:smarttags place 0GDd 7X V ,V¢a APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY Condaisy Richard Normal Condaisy Richards DIVISION OF BANKING & INSURANCE APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY Title