To Whom It May Concern: As requested, attached are the applications and a copy of Section 772 of Title 22 Virgin Islands Code regarding nonresident agents and brokers. The completed application must be returned with the following: 1. A fee of $800.00 for a nonresident broker’s license or a fee of $600.00 for a nonresident agent’s license. The check must be made payable to the Government of the Virgin Islands. 2. A certified copy of the applicant’s current license from state of domicile showing the issuance as well as the expiration date. 3. A statement from your state’s Insurance Department stating that similar license privilege will be extended to residents of, or corporations created under the laws, of the Virgin Islands. A copy of the applicable statute will suffice. If the application is for a nonresident broker a bond in the sum of $10,000 must be submitted to our Division. This bond must be maintained while the license is in effect. Further, a firm or corporation being licensed must also have licensed an individual to exercise the power conferred by the license. I’ve also attached the listings of all authorized insurance companies in this territory. Should you need any additional information, please feel free to call me. Sincerely, Attachment OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE ORIGINAL APPLICATION FOR INSURANCE LICENSE (ORGANIZATION) Please Print or Type . LICENSE TYPE: Check only one box in categories (a) and (b); Applicant must complete a separate application for each license a) (MAgent OBroker Olndependent Adjuster OPublic-Adjuster OSurplus Line Broker JGeneral Agent b) OlLife & Health OProperty & Casualty OTitle OA! Lines DOther c) (Resident GNonresident . NAME OF ORGANIZATION: E.LN.: Email: Website: PRINCIPAL BUSINESS ADDRESS: a) PHYSICAL: = Street : : Apt/Suite # City State Zip Code Telephone number ( )- - Fax number ( )- - b) MAILING: Street/P.O. Box Office/Suite# City State Zip Code Will the organization use a fictitious (DBA) name to transact business? DYes ONo If yes, please indicate such name: Has the organization submitted to the Division of Banking and Insurance, within the last year, an application for which a license has not been issued? OYes ONo If yes, list name under which the application was made, date filed, and license type requested: 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. Ifthe Organization hold or has ever held an insurance license, complete the following: ON/A Type of License & License State Resident or Date License Held Number Nonresident From To 7. RESIDENT AGENT APPLICANTS (Including general agent or manager): ON/A List names of 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. 8. RESIDENT BROKER APPLICANTS: ON/A a) List the names of the 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) Broker Bond Number: Surety Company: 9. SURPLUS LINES BROKER APPLICANTS: GN/A a) List the names of all “unauthorized insurers” or “surplus lines carriers” with which surplus lines business is conducted. (Note: surplus lines business must be placed only with unauthorized insurers which have been deemed by the Commissioner of Insurance to be eligible to engage in surplus lines business in the Territory.) b) Broker Bond Number: Surety Company: 10. NONRESIDENT AGENT/BROKER APPLICANTS: ON/A List all Jurisdictions in which the organization is or has been licensed to do business: DATE STATE TYPE OF LICENSE FROM TO 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 11. NON-RESIDENT AGENT/BROKER APPLICANTS: ON/A List name(s) of authorized companies which the organization represents or through which business is being placed. You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable. 12, NONRESIDENT BROKER APPLICANTS: ON/A Broker Bond Number: Surety Company: 13. INDEPENDENT ADJUSTER APPLICANTS: ON/A List Companies with which you are affiliated. You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable. 14. PUBLIC ADJUSTER APPLICANTS: ON/A Public Adjuster Bond Number: Surety Company: 15. LIST EACH PERSON WHO WILL BE AUTHORIZED TO TRANSACT INSURANCE BUSINESS UNDER THE LICENSE APPLIED FOR AND HIS/HER RELATIONSHIP TO THE ORGANIZATION. Relationship to the organization must be that of an EMPLOYEE, OFFICER, or PARTNER, as appropriate to the organization type.) An Individual license is required for each person named, and a separate application form must be completed and submitted by such person. NAME LAST FIRST MI RELATIONSHIP TO ORGANIZATION 16. PARTNERSHIP APPLICANT ONLY: ON/A List name and address of all partners and attach the partnership agreement, if any. If no agreement, so state. (Attach a separate sheet if more space is needed.) NAME 0 * LAST FIRST MI RESIDENCE SOCAIL SECURITY #) “% Ownership 17. CORPORATE APPLICANTS ONLY: ON/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 3 Complete the following and attach a copy of the Articles of Incorporation: (Attach a separate sheet if more space is needed) a) Corporate # Date Incorporated _ State in which incorporated (Attach relevant corporate documents) b) List each Officer, Director, and Stockholder who owns 10% or more of the corporation’s stock: LAST NAME FIRST MI RESIDENCE SOCAIL SECURITY # | % Ownership President Vice President Treasurer Director Director Director Stockholder 18. LIMITED LIABILITY COMPANIES ONLY: ON/A Complete the following and attach a copy of the Articles of Organization: (Attach a separate sheet if more space is needed) a) LLC# Date Incorporated th State in which incorporated (Attach relevant corporate documents) b) List each Officer, Director, and Stockholder who owns 10% or more of the corporation’s stock: LAST NAME FIRST MI RESIDENCE S.S.N % Ownership 19. Is there any person within the organization, other than named in questions (15, 16, 17 and 18), who directs the affairs of the organization? OYes ONo If yes, list name, residence address, and social security number of such person(s): 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 NAME LAST FIRST MI RESIDENCE SOCAIL SECURITY # | % Ownership 20. Has the organization or have any of its members, managers, partners, principals, directors, officers or shareholders owning a 10% or more interest in the organization, or any person identified in question 19 above 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 ONo (If yes, please explain in detail on a separate sheet if needed.) 21. Are there currently any disciplinary actions pending against the organization or any of its members, managers, partners, principals, directors, officers or shareholders owning a 10% or more interest in the organization, or any person identified in question number 19? Yes ONo (If yes, please explain in detail on a separate sheet if needed.) 22. Has any of the organization’s members, managers, partners, principals, directors, officers or shareholders owning a 10% or more interest in the organization or any person identified in question number 19 ever been arrested, charged or convicted of a crime? Yes ONo (If yes, please explain in detail on a separate sheet if needed.) 23. Has the organization or have any of its members, managers, partners, principals, directors, officers, or any shareholders owning a 10% or more interest in the organization, or any person identified in question number 19, been involved in any bankruptcy or receivership proceedings within the past ten years? Yes ONo (if yes, please explain in detail on a separate sheet if needed.) 24. Has the organization or any of its members, managers, partners, principals, directors, officers, or any shareholders owning a 10% or more interest in the organization, or any person identified in question number 19, been indebted, other than for current accounts, to any insurance company or person for unpaid insurance premium? OYes ONo (if yes, please explain in detail on a separate sheet if needed.) **Tf the answer is "YES" to questions (20), (21), (22) (23) and (24), please attach a statement, signed by a person authorized by the organization, 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. IMPORTANT NOTICES: Failure to fully answer all questions on application 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 (20),(21), (22) (23) and (24) and any changes in the business operations of the Applicant. The following items are also needed for licensure of Brokers, Public Adjusters and Surplus Lines Brokers: 1) Broker’s Bond 2) Surplus Lines’ Bond 3) Public Adjuster’s Bond 4) Fee Information for Original 5) Identification (Gov’t issued, i.e.: Driver’s license, Passport, Vote’s Registration Card, etc.) 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 All checks and money orders must be made payable to Government of the U.S. Virgin Islands. RESIDENT ORIGINAL FEE BOND Agent $300.00 N/A Broker 400.00 10,000.00 Surplus Line Broker 400.00 10,000.00 Adjuster (Independent/Public) 300.00 5,000.00 (Public Only) Solicitor 300.00 NIA General Agent 600.00 NIA NON-RESIDENT ORIGINAL FEE BOND Agent 600.00 N/A Broker 800.00 10,000.00 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. Name Date (Print) Signature Title Subscribed and sworn to before me this _day of , 200 SEAL Notary Public FOR OFFICE USE ONLY Receipt Number: Date: Amount: $ 5049 Kongens Gade, St. Thomas, VI 00802-6487 « Tel: (340) 774-7166 * Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, V] 00820 + Telephone: (340) 773-6459 « Fax: (340)-719-3801 Page 6