OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF BANKING AND INSURANCE 
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 
 
INDIVIDUAL REGISTRATION FORM 
NONRESIDENT INDEPENDENT ADJUSTER 
1. NAME OF APPLICANT: 
Mr. 
Mrs. 
Ms. 
Miss 
Last 
 
First 
Middle Name:
 
 
2. IDENTIFICATION INFORMATION: 
S.S.N. 
 
Sex:  M  F   
Date of Birth:  
 
Place of Birth:  
 
 
 
             MM/DD/YYYY 
 
 
 
                      City, State 
Email: 
 
Website: 
 
3. BUSINESS NAME AND ADDRESS: Name: _____________________________(P.O. Box not acceptable)  
Street ____________________________________________   Apt/Suite # ____________________________ 
 
City _________________________________ State _______________________ Zip Code _______________ 
Business Phone No: (         ) - ________ - _____________ Fax Phone No: (         ) - ______ - ______________ 
4. PHYSICAL ADDRESS IN STATE OF DOMICILE: (P.O. Box not acceptable) 
Street ____________________________________________   Apt/Suite # ____________________________ 
 
City _________________________________ State _______________________ Zip Code _______________ 
 
Phone No: (               ) - _________ - _________________ 
5. PHYSICAL ADDRESS WHILE IN THE VIRGIN ISLANDS:  
Street _____________________________________     Apt/Suite # ___________________________ 
City _________________________________ State _______________________   Zip Code ______________ 
Phone No: (               ) - _________ - _________________ 
 
BY SIGNATURE HERETO I hereby certify that the information provided in this application is true and correct. 
 
Date:_____________  
 
 
________________________________   
 
 
 
 
 
 
      Applicant's Signature 
 
Subscribed and Sworn to before me this ____ day of ___________________, 20___. 
 
 
 
 
 
 
 
 
 
 
________________________________ 
 
 
 
 
 
 
 
 
 
 
Notary Public 
 
 
 
 
 
 
 
 
 
Commission Expires:_______________ 
 
 
 
 
 
 
 
 
 
Commission Number:_______________ 
 
NOTE:  You are required to attach a copy of your adjuster's license from your state of domicile along with a copy of your 
picture identification.