USVI Public Records

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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 RENEWAL APPLICATION FOR INSURANCE LICENSE (ORGANIZATION) 1. LICENSE TYPE: [Check only one box in categories (a) and (b); Applicant must complete a separate application for each license] a)
Agent
Broker
Independent Adjuster
Public-Adjuster
Surplus Line Broker
General Agent b)
Life & Health
Property & Casualty
Title
All Lines
Other _______________ 2. NAME OF ORGANIZATION: E.I.N.: Email: Website: 3. PRINCIPAL BUSINESS ADDRESS: Address Change from last renewal? a) PHYSICAL: Street __________________________________________ Apt/Suite # ________ City _____________________________ State _________________ Zip Code ________________ Telephone number ( ) - _______ - ___________ Fax number ( ) - _______ - __________ b) MAILING: Street/P.O. Box _________________________________Office/Suite# _________ City _________________________________ State ________________ Zip Code ___________ 4. AGENT/GENERAL AGENT APPLICANT(S) ONLY: List name(s) of admitted company or companies which the organization represents and from which it has 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.) 5. BROKER APPLICANTS ONLY: a) List name(s) of admitted companies with which business has been 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) 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 6. SURPLUS LINES BROKER: a) List the names of all “unauthorized insurers” or “surplus lines carriers” with which surplus lines business is conducted. (Note: surplus lines business must be placed only with unauthorized insurers which have been deemed by the Commissioner of Insurance to be eligible to engage in surplus lines business in the Territory.) b) Broker Bond Number: _______________________ Surety Company: ______________________ 7. INDEPENDENT ADJUSTER APPLICANTS: List Companies with which you are affiliated (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) 8. PUBLIC ADJUSTER APPLICANTS: Public Adjuster Bond Number: ___________________ Surety Company_______________________ 9. Pursuant to Title 22, Section 754(b), Virgin Islands Code, list the names of each individual authorized to exercise the powers conferred by the license applied for: NAME: LAST FIRST M.I. 10. Has the organization or have any of its members, managers, partners, principals, directors, officers or shareholders owning a 10% or more interest in the organization, or any person identified in question number 9 above 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?
Yes
No (If yes, please explain in detail) (Attach a separate sheet if needed.): 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 11. Are there currently any disciplinary actions pending against the organization or any of its members, managers, partners, principals, directors, officers or shareholders owning a 10% or more interest in the organization, or any person identified in question number 9?
Yes
No (If yes, please explain in detail) (Attach a separate sheet if needed.): 12. Has any of the organization’s members, managers, partners, principals, directors, officers or shareholders owning a 10% or more interest in the organization or any person identified in question number 9 ever been arrested, charged or convicted of a crime?
Yes
No (If yes, please explain in detail) (Attach a separate sheet if needed.): 13. Has the organization or have any of its members, managers, partners, principals, directors, officers, or any shareholders owning a 10% or more interest in the organization, or any person identified in question number 9, been involved in any bankruptcy or receivership proceedings within the past ten years?
Yes
No (If yes, please explain in detail) (Attach a separate sheet if needed.): 14. Has the organization or any of its members, managers, partners, principals, directors, officers, or any shareholders owning a 10% or more interest in the organization, or any person identified in question number 9, been indebted, other than for current accounts, to any insurance company or person for unpaid insurance premium?
Yes
No (If yes, please explain in detail) (Attach a separate sheet if needed): **If the answer is “YES" to questions (10), (11), (12), (13) and (14), please attach a statement, signed by a person authorized by the organization, 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 (10), (11), (12), (13) and (14) and any changes in the business operations of the Applicant. 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 Date: Name of Organization: By: __________________________________________ Print Name __________________________________________ Signature __________________________________________ Title NOTE: Please enclose the appropriate renewal fee(s) with application on or before December 31st. Make check or money order payable to Government of the U.S. Virgin Islands. Failure to fully answer all questions on application will result in the application being returned to applicant. Any application received after January 15, 2007 will be assessed a late penalty of $50.00. 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)