Government of the United States Virgin Islands 
Office of the Commissioner – Division of Banking, Insurance and Financial Regulation 
#5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 
1131 King Street, Suite 101, Christiansted, V.I.   00820 
TEL-340-774-7166              FAX-340-774-5590 
TEL-340-773-6459              FAX-340-719-3801 
 
APPOINTMENT OF SOLICITOR 
 
 
Pursuant to Title 22, Section 762, of the Virgin Islands Code, the 
undersigned Producer hereby applies for authorization for 
 
________________________________________________________________________ 
(Name of Solicitor) 
 
________________________________________________________________________ 
(Business Address of Solicitor) 
 
________________________________________________________________________ 
(Kind[s] of insurance solicitor will write) 
 
The above Solicitor is hereby authorized to solicit and accept applications on 
behalf of the following Producer within the U.S. Virgin Islands effective 
_________________.   
       (Date) 
 
 
______________________________________________________________________________ 
(Name of Insurance Producer) 
 
 
_______________________________________        __________________________________ 
     Authorized Signatory of Producer to appoint/terminate                                             Signature 
 
 
(DO NOT WRITE BELOW THIS LINE) 
This document is hereby approved and filed in the Office of the Commissioner of Insurance:   
 
Solicitor’s license number ____________________. 
 
 
_______________________________________                    _____________________________ 
            Commissioner of Insurance                                                                 Date  
                                                      
 
STATEMENT OF AGREEMENT TO SERVE AS INSURANCE SOLICITOR 
 
 
 
Pursuant to Title 22, Section 762, of the Virgin Islands Code, I hereby agree to 
 
serve as an insurance solicitor for ____________________________________________  
                                                                                                      (Name of License Producer) 
 
of ___________________________________  in and for the Virgin Islands of the United     
(City)                          (State) 
 
States.  I understand that, pursuant to Title 22, Section 762, I do not have the power to 
cover any kind of insurance for which the producer by whom I am employed is not then 
licensed.  Further, I do not have the power to bind an insurer upon or with reference to 
any risk or insurance contract, or to countersign insurance contracts. 
 
_________________________________ 
               Solicitor’s Signature 
 
 
 
 
Subscribed and sworn to before me this ____ day of _______________, 20_____  
 
at _________________________________. 
        (City)                                              (State) 
 
 
 
_________________________________ 
Notary Public