USVI Public Records

Document text

To Whom It May Concern: Attached are the original insurance applications for an individual or an organization. The completed application must be returned with the following: 3. 1.A fee of $800.00 for a nonresident broker’s license. A fee of $600.00 for a nonresident agent’s license and a fee of $300.00 for an Independent or Public Adjusters. The check must be made payable to the Government of the Virgin Islands. 2. For All Non-Residents Licensee: A copy of the applicant’s current license or a letter of certificate from state of domicile showing the issuance as well as the expiration date. If the application is for a non-resident broker, a bond in the sum of $10,000.00 must be submitted to our Division. The bond must be procured through a company authorized and licensed to conduct business in the Virgin Islands. This bond must be maintained while the license is in effect. For Public Adjuster’s, a bond in the sum of $5,000.00 must be submitted to our office. The bond must be procured through a company authorized and licensed to conduct business in the Virgin Islands. This bond must be maintained while the license is in effect. Independent Adjusters must specify the name(s) of all licensed insurers that the licensee represents. For All Non-Residents Licensee: If the application is for an organization, a copy of the corporate documents are required; Articles of Incorporation and By-laws. 7. For all agent licenses, applicants including agencies must be appointed as its agent by one or more companies licensed to place business in the Virgin Islands, subject to the issuance of the license. An appointment for all companies listed on the application must be submitted with a fee of $25.00 for each company appointment. If you have an appointment in your state for the companies listed, you are required to submit that appointment with a filing fee of $25.00. Non-submission of these appointments will cause a delay in the approval of your application. Further, a firm or corporation being licensed must also have licensed an individual to exercise the power conferred by the license. Should you need any additional information, please feel free to call me. OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE ORIGINAL INSURANCE APPLICATION FOR RESIDENT OR NON-RESIDENT INSURANCE LICENSE (INDIVIDUAL) LICENSE TYPE: Check box that applies for each category. Applicant must complete a separate application for each license type. a) O Resident © Non-Resident b) OAgent OBroker Olndependent-Adjuster OPublic-Adjuster OSolicitor OSurplus Line Broker (residents only) OGeneral Agent (residents only) OGeneral Manager (residents only) c) OLife & Health OProperty & Casualty OTitle OAnnuities ODisability OSurety OVariable Annuities OVariable Contracts OVariable Life NAME OF APPLICANT: OMr. Ors. OMs. Last First Middle Name: IDENTIFICATION INFORMATION: S.S.N. Sex: OM OF Date of Birth: Place of Birth: MM/DD/YYYY City, State . BUSINESS ADDRESS: (P.O. Box not acceptable) QAddress Change from last renewal? Street Apt/Suite # City State Zip Code Business Phone No: ( )- - Fax Phone No: ( )- - Email: Website: RESIDENCE ADDRESS: (P.O. Box not acceptable) DAddress Change from last renewal? Street Apt/Suite # City State Zip Code Home Phone No: ( )- - MAILING ADDRESS: Business MResidence QAddress Change from last renewal? Street/P.O. Box Apt/Suite # City State Zip Code Do you intend to use a fictitious (DBA) name to transact insurance business? DYes ONo If yes please list name 5049 Kongens Gade, St. Thomas, VI] 00802-6487 « Tel: (340) 774-7166 * Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, V1 00820 » Telephone: (340) 773-6459 * Fax: (340)-719-3801 Page | 8. Are you now or have you ever used any name other than shown in (2) or (7)? Yes ONo If yes, list names, dates, and reasons used. Name | Date Reason 9. RESIDENT OR NON-RESIDENT LIFE AGENT APPLICANTS ONLY: 0 N/A a) If you intend to act as a Variable Contract Agent, are you registered with the Division of Banking and Insurance? (Yes CINo (If yes, provide your BD-A registration number. If no, state the reason why you have not registered.) b) If you intend to act as a Variable Contract Agent, are you registered with NASD? OYes OINo (Provide evidence of same. 10. GENERAL AGENT OR GENERAL MANAGER APPLICANTS (residents only): 0 N/A List the names of the authorized companies which you will 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.) 11. RESIDENT OR NON-RESIDENT AGENT APPLICANTS: 0 N/A a) List names of the authorized companies licensed in the Virgin Islands through which you will 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.) 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 b) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated 12, RESIDENT OR NON-RESIDENT BROKER APPLICANTS: 0 N/A a) List names of authorized companies through which business will be placed. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) b) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated. c) Broker Bond Number Expiration Date Surety Company 13. SOLICITOR APPLICANTS: 0 N/A Provide the name of the Agent and/or Agency with which you are appointed. 14. SURPLUS LINE BROKER APPLICANTS ONLY: 0) N/A a) List the names of all “unauthorized insurers” or “surplus lines carries” 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 applicant: (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) Eligible Unauthorized Insurers in the Virgin Islands b) Broker Bond Number Expiration Date 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 + Telephone: (340) 773-6459 « Fax: (340)-719-3801 15. RESIDENT ADJUSTER APPLICANTS ONLY: 0) N/A If you are an Office Manager, list names of adjusters working directly under your supervision: 16. RESIDENT OR NON-RESIDENT INDEPENDENT ADJUSTER APPLICANTS: 0) N/A List Companies with which you are affiliated: 17, RESIDENT OR NON-RESIDENT PUBLIC ADJUSTER APPLICANTS: 0 N/A Public Adjuster Bond Number: Surety Company: 18. ALL APPLICANTS: If you hold or have ever held an insurance license, complete the following: O N/A . Resident Date License Held Type of License State Nonresident From To 19. ALL APPLICANTS: List your places of residents for the past five years. Bion Le Street City State Postal Code (MM/YYYY) (MM/ YYYY) 5049 Kongens Gade, St. Thomas, V1 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 20. ALL APPLICANTS: List your occupation (employment) for the past five years to current: From To Employer Name Duties Performed (MM/YYYY) | (MM/YYYY) Address 21. a) Have you ever had any professional, vocational or business license denied, suspended, revoked or restricted or a fine imposed by any Public Authority, or withdrawn any application for or surrendered any such license to avoid disciplinary action? OYes ONo = (If yes, please explain fully on a separate sheet) b) Are there currently any disciplinary actions pending against you? OYes ONo (If yes, please explain fully on a separate sheet) 22. Have you ever been arrested, charged or conviction of a crime? DYes ONo If yes, attach a detailed statement, signed by you, of the events which led to the charges including the dates and places. If the matter was heard in court, attach copies Certified by the Court, of the Criminal Complaint and the Sentencing Order showing the final judgment.) 23. Have you been indebted, other than current accounts, to any insurance company or person for unpaid insurance premiums or return premiums? OYes ONo (if yes, please explain fully on a separate sheet) 24. Have you, the past ten years, ever been involved any bankruptcy or receivership proceedings? Yes CINo (ff yes, please explain fully on a separate sheet) IMPORTANT NOTICES: Failure to fully answer all questions on application and non-submission of the required documents will result in the application being returned to applicant. Additionally, 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 (21), (22), (23) and (24) any changes in the business operations of the Applicant. If the answer is "YES" to questions (21), (22), (23) and (24) 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. 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 APPLICANT’S CERTIFICATION: I certify under penalty of perjury that I have read the foregoing application and know the contents thereof and that each statement therein made is true and correct. I understand that any false statement may subject my application to denial and may subject my license(s) to suspension or revocation. Further, I authorize disclosure to the insurance commissioner of all financial institutions’ records of any fiduciary accounts for the duration of this license. Date Signature Print Name The following items are needed for licensure: 1) Identification (Gov’t issued, i.e.: Driver’s license, Passport, Vote’s Registration Card, etc.) 2) Tax Clearance Letter ** *Brokers, Public Adjusters and Surplus Lines Brokers only 3) License or Letter of Certification from State of **Non-Resident Adjusters and All Residents only Domicile (non-resident applicants) ***FOR Agents, Solicitors and General Agent only 4) Broker’s Bond * ****For Agent and Solicitors only 5) Surplus Lines’ Bond * 6) Public Adjuster’s Bond * 7) Three Letters of Recommendation** 8) Written Examination** 9) Original License Fee Appointment Forms*** 10) Appointment Fee**** RESIDENT ORIGINAL FEE BOND Solicitor $300.00 N/A Agent $300.00 N/A Appointment Fee (Agent/Solicitor) $ 25.00 N/A General Agent $600.00 N/A Resident Broker $400.00 10,000.00 Surplus Line Broker $400.00 10,000.00 Adjuster (Independent/Public) $300.00 5,000.00 (Public Only) NON-RESIDENT ORIGINAL FEE BOND Agent $600.00 N/A Broker $800.00 10,000.00 Adjuster (independent/Public) $300.00 5,000.00 (Public Only) All checks and money orders must be made payable to Government of the U.S. Virgin Islands. FOR OFFICE USE ONLY Receipt Number: Date: Amount: $ (REV: 09/2012) 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 Appointment of Agent oe DD ee 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 AN AUTHORIZED SIGNATORY DESIGNATED TO APPOINT AND TERMINATE AGENTS IN THE COMPANY APPLICATION) (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 DATE Commissioner of Insurance 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, I shall keep at my address as shown on my license, during all business hours a complete record of all transactions to include applications for and policies of insurance placed by or through me pursuant to Title 22, Section 784, of the Virgin Islands Code, 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)