Appointment of Agent
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COMMISSIONER OF INSURANCE
CHARLOTTE AMALIE
ST. THOMAS, VIRGIN ISLANDS
Dear Sir:
Pursuant to Title 22, Section 753, of the Virgin Islands code, the undersigned
insurance company hereby applies for authorization for:
_________________________________________________________________
(NAME OF AGENT)
________________________________________________________________
(BUSINESS ADDRESS OF AGENT)
_________________________________________________________________
(KINDS OF INSURANCE AGENT 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__________________________
DATE
_______________________________________________________________
(NAME OF INSURANCE COMPANY)
________________________________________________________________
(TO BE SIGNED BY A RESPONSIBLE OFFICER OF THE COMPANY)
________________________________________________________________
(PRINT NAME)
(DO NOT WRITE BELOW THIS LINE)
_________________________________________________________________
This document
is hereby
approved
and
filed
in
the Office of the
Commissioner of Insurance,
Serial Number_________________ Agent’s License Number___________
____________________________________
Commissioner of Insurance
____________________________________
DATE
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
____________________________________________in and for the Virgin Islands of
the 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, if I sign policies, I will maintain an office within the Virgin Islands
and keep therein at all times a complete record of all applications for and policies of
insurance placed by or through me, and will not sign any policies in blank to be
issued outside my office.
____________________________________
____________________________________
_______________________________________________________________________
Subscribed and sworn to be fore me this __________day of ____________________,
20___________at________________________________________________________
____________________________________________
(Notary Public)