Government of the United States Virgin Islands  
Office of the Commissioner of Insurance 
Division of Banking, Insurance and Financial Regulation 
#5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 
 
TEL-340-774-7166              FAX 340-774-5590 
 
 
 
CONTACT PERSON(S) FOR ________________________________________ 
                                                                       (Please indicate company’s name) 
1. 
Company’s President: __________________________________________ 
Mailing Address: ______________________________________________ 
 
 
           ______________________________________________ 
Telephone No._______________________ Fax No.___________________  
E-Mail_____________________________ 
 
2. Contact Person – Licensure and related filings 
 
Name/Title: _____________________________________________________
 
Mailing Address: _________________________________________________ 
 
 
 
        _________________________________________________ 
 
Telephone No.____________________Fax No._________________________ 
 
E-Mail__________________________ 
 
  
 
 
3. Contact Person – Consumer Complaints 
 
Name/Title: _____________________________________________________
 
Mailing Address: _________________________________________________ 
 
 
 
        _________________________________________________ 
 
Telephone No.____________________Fax No._________________________ 
 
E-Mail__________________________ 
 
4. Contact Person – Company’s Statutory Deposit 
 
Name/Title: _____________________________________________________
 
Mailing Address: _________________________________________________ 
 
 
 
        _________________________________________________ 
 
Telephone No.____________________Fax No._________________________ 
 
E-Mail__________________________