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 
 
COMPANY REGISTRATION FORM 
NONRESIDENT INDEPENDENT ADJUSTER 
 
1. Company Name: __________________________________________ 
E.I.N. ___________________________    
2. Physical Address in state of Domicile:  
Street ___________________________________ Apt/Suite # ________ 
City _____________________________ State _________________ 
Zip Code ________________ 
Telephone number (          ) - _______ - ___________ Fax number (         ) - _______ - __________ 
b) MAILING: Street/P.O. Box _________________________________Office/Suite# _________ 
City _________________________________ State ________________ Zip Code __________ 
3. Physical Address while residing in the Virgin Islands:  License Number ____________ 
 
Street ___________________________________ Apt/Suite # ________ 
City _____________________________ State _________________ 
Zip Code ________________ 
Telephone number (          ) - _______ - ___________ Fax number (         ) - _______ - __________ 
b) MAILING: Street/P.O. Box _________________________________Office/Suite# _________ 
City _________________________________ State ________________ Zip Code __________ 
4. Name of Person’s working on behalf of Company while in the Virgin Islands: 
Name:___________________________  Telephone Number _________________ 
Name:___________________________  Telephone Number _________________ 
 
BY SIGNATURE HERETO I hereby certify that the information provided in this application is true and 
correct. 
 
Date:__________  
Company's Name:_______________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
By:___________________________________ 
 
 
 
 
 
 
 
Title:_________________________________ 
 
 
Subscribed and Sworn to before me this ______ day of _________________, 20___. 
 
 
 
 
 
 
 
 
 
 
________________________________ 
 
 
 
 
 
 
 
 
 
 
 
Notary Public 
 
 
 
 
 
 
 
 
 
Commission Expires:_______________ 
 
 
 
 
 
 
 
 
 
Commission Number:_______________ 
 
NOTE:  Please attach a copy of the Company's adjusting license from state of domicile along with a list of all 
adjusters working under the company's license.