USVI Public Records

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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 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 RENEWAL APPLICATION FOR THIRD PARTY ADMINISTRATOR Please Print or Type Please check the appropriate box: A Sole Proprietor  A corporation  A General Partner  A Limited Partnership  Other _______________ If a Corporation or Partnership, attach a list of all current officers of the corporation or partners of the Part- nership, Social Security Number and Date of Birth must be included for each person listed. GENERAL INFORMATION ⎕ $650.00 FEE 1. Legal Name of Applicant: _______________________________________________________ 2. E.I.N: ____________________________ S.S.N.: ___________________________ 3. Insurance Company(ies) Affiliation: ______________________________________________________________________________________ ______________________________________________________________________________________ 4. Business Physical Address: Street _______________________________ Office/Suite # _____ City _____________________________ State ________________ Zip Code ______________ Telephone Number ( )- _______ - ___________ Fax Number ( )- _______ - _________ Email: _________________________ Website: __________________________________ 5. Mailing Address: Street/P.O. Box ____________________________ Apt/Suite # ______ City _________________________________ State ________________ Zip Code _________ Telephone Number ( )- _______ - ___________ Fax Number ( )- _______ - _________ 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 .LICENSURE ACTIVITIES AND LINES OF BUSINESS 7. Check each section below as it relates to the applicant’s activities for residents of the Virgin Islands. Check All Those That Apply: Collect charges or premiums for any plans  Life Insurance Coverage Adjusts or settles claims for any plans Health Insurance Coverage  Annuities Please provide a thorough description of activities: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ BACKGROUND INFORMATION Since the issuance of the applicant’s last license: 8. (a) Does the applicant or the two signing officers hold or an agent’s or broker’s license in the U.S. Virgin Islands? Yes No (If yes, please explain in detail. Attach a separate sheet if needed.): (b) Has the applicant or either of the two signing officers been penalized or fined, had a license refused, suspended or revoked by the insurance department of any state or country?  Yes  No (If yes, please explain in detail. Attach a separate sheet if needed.): 9. Has the applicant or either of the two signing officers below ever been convicted of or pled nolo contendere (no contest) to any misdemeanor or felony or currently have pending any such charges? (For these purposes, misdemeanor does not include minor traffic violations.) Yes No (If yes, please explain in detail. Attach a separate sheet if needed.): FINANCIAL RESPONSIBILITY AND SECURITY INFORMATION 10. All licensed administrators are required to maintain an errors and omissions insurance policy. In the space below, please list the details regarding your coverage and attach a copy of the policy declarations page to this application. Policy Number _____________________ Issuing Company _____________________________ Amount of Coverage _________________ Policy Expiration ____________ 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 11. (a) All Licensed Administrators are required to maintain financial responsibility in the form of a Fidelity Bond or a clean irrevocable and unconditional and ever-green letter of credit in an amount set forth in the attached checklist. In the space below, please list the details re- garding your financial requirements and attach a copy of the bond declarations page or letter of credit agreement to this application. Policy/LOC Number ________________ Issuing Company/Bank ______________________ Amount of Coverage/LOC _________________ Policy Expiration ____________ Average Amount of Funds Held by the Applicant: ________________ (For All Plans) (Total of Last 12 months divided by 12 equals average) Date of Year End: ____________ (b) All licensed Administrators are required to maintain special fiduciary accounts depending on the purpose for which the money collected by the Administrator will be used. These accounts must be held in a financial institution located in the Territory. In the designated space below, please list the details regarding the type of fiduciary account(s) maintained by the Administrator and attach a copy of proof that such accounts have been established. ACCOUNT #1 Name of Financial Institution _______________________________________________________________ Type of Account ⎕ TPATFA ⎕ CASA Account Number _________________________________________________________________________ Purpose of Account _______________________________________________________________________ ____________________________________________________________ ACCOUNT #2 (IF APPLICABLE) Name of Financial Institution _______________________________________________________________ Type of Account ⎕ TPATFA ⎕ CASA Account Number ________________________________________________________________________ Purpose of Account ______________________________________________________________________ ____________________________________________________________ *Applicant is under a continuing obligation to notify the division of any changes in the information provided in or with this application 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 CERTIFICATION I _______________________________ certify that I am authorized to file this certification on behalf of the (Name and Title) applicant; that the information set forth herein is true to the best of my knowledge, belief and information; and that the Commissioner of Insurance may rely on the information set forth in the application in determining whether to grant a license. I further certify that ______________________ will comply with the insurance laws of the Virgin Islands and (Name of Applicant) all other applicable rules and regulations. _____________________________ _____________________________ Signature of Officer or Director Full Legal Name (Type or Print) _____________________________ _____________________________ Title Date State of ______________________ County of ____________________ Personally, appeared before me the above named __________________________ personally known to me, who, being duly sworn, deposes and says that he executed the above instrument and that the statements and an- swers contained therein are true and correct to the best of his knowledge and belief. Subscribed and sworn to before me this ____ day of _________________ 20___. ____________________________ Seal (Notary Public) My Commission Expires _________________