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 • Tel: (340) 773-6459 • Fax: (340) 719-3801 Page 1 RENEWAL APPLICATION FOR INSURANCE LICENSE (INDIVIDUAL) 1. LICENSE TYPE: [Check only one box in categories (a) and (b); Applicant must complete a separate application for each license] a) Agent Broker Indep.- Adjuster Public-Adjuster Surplus Line Broker Solicitor General Agent b) Life & Health Property & Casualty Title All Lines Other _____________ 2. NAME OF APPLICANT: Mr. Mrs. Ms. Miss Last First Middle Name: 3. INDENTIFICATION INFORMATION: S.S.N. Sex: M F Email: Website: 4. BUSINESS PHYSICAL ADDRESS: Address Change from last renewal? Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Business Phone No: ( ) - ________ - _____________ Fax Phone No: ( ) - ______ - ______________ 5. RESIDENCE ADDRESS: (P.O. Box not acceptable) Address Change from last renewal? Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Home Phone No: ( ) - _________ - _________________ 6. MAILING ADDRESS: Business Residence Address Change from last renewal? Street/P.O. Box _____________________________________ Apt/Suite # ___________________________ City _________________________________ State _______________________ Zip Code ______________ 7. Have you been arrested, charged or convicted of a crime since your last renewal? Yes  No (If yes, please explain in detail. Attach a separate sheet if necessary.) 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340) 719-3801 Page 2 8. Have you, since the issuance of your last license, had any professional, vocational or business license denied, suspended, revoked or restricted or a fine imposed by any licensing authority or withdrawn any application for or surrendered any such license to avoid disciplinary action? Yes No (If yes, please explain in detail. Attach a separate sheet if necessary.) 9. Are there currently any disciplinary actions pending against you? Yes No (If yes, please explain in detail. Attach a separate sheet if necessary.) 10. Have you, since the issuance of your last license, been indebted, other than for current accounts, to any insurance company or person for unpaid insurance premiums or return premiums? Yes No (If yes, please explain in detail. Attach a separate sheet if necessary.) 11. Have you, since the issuance of your last license, been involved in any bankruptcy or receivership proceedings? Yes  No (If yes, please explain in detail. Attach a separate sheet if necessary.) 12. AGENT/GENERAL AGENT APPLICANT(S) ONLY: List name(s) of authorized companies you 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.) Name of Agency in the U.S. Virgin Islands with which you are affiliated: 13. BROKER APPLICANTS ONLY: List name(s) of admitted company or companies through which business is placed. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) Name of Agency in the U.S. Virgin Islands with which you are affiliated: Broker Bond Number: Surety Company: 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340) 719-3801 Page 3 14. SURPLUS LINE BROKER APPLICANTS ONLY: List the name(s) of all “unauthorized insurers” or “surplus lines carriers” that are eligible to conduct surplus lines business in the Virgin Islands with which arrangements have been made to accept or which are considering the acceptance of surplus lines business offered by the applicant. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) Name of Agency in the U.S. Virgin Islands with which you are affiliated: Broker Bond Number: Surety Company: 15. ADJUSTER APPLICANTS ONLY: If you are an Office Manager, list names of adjusters working directly under your supervision: 16. PUBLIC ADJUSTER APPLICANTS: Public Adjuster Bond Number: Surety Company: 17. INDEPENDENT ADJUSTER APPLICANTS: List Companies with which you are affiliated 18. LIFE AGENT APPLICANTS ONLY: a) If you are acting as a Variable Contract Agent, are you registered with the Division of Banking and Insurance? Yes No (If yes, provide your BD-A registration number). (If no, state the reason why you have not registered). b) If you are acting as a Variable Contract Agent, are you registered with FINRA? Yes No **If the answer is "YES" to questions 7, 8 9, 10 and 11, please attach a notarized statement 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 NOTICE: 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 7, 8 9, 10 and 11, and any changes in the business operations of the Applicant. Note: Please enclose the appropriate renewal fee(s) with application on or before December 31st. Any application received after January 15, 2007 will be assessed a late penalties of $50.00. 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: (340) 774-7166 • Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340) 719-3801 Page 4 (Make check or money order payable to Government of the U.S. Virgin Islands.) DATE: ____________________ Signature: ______________________________________ RESIDENT RENEWAL FEE BOND Agent $100.00 N/A Broker $200.00 $10,000.00 Surplus Line Broker $400.00 $10,000.00 Adjuster (Independent/Public) $150.00 $ 5,000.00 (Public Only) Solicitor $100.00 N/A General Agent $350.00 N/A FOR OFFICE USE ONLY Receipt Number: _______________________ Date: _______________ Amount: _________________ (REV: 10/07)