Appointment of Agent
Government of the United States Virgin Islands Office of the Commissioner – Division of Banking, Insurance and Financial Regulation #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 1131 King Street, Suite 101, Christiansted, V.I. 00820 TEL-340-774-7166 FAX-340-774-5590 TEL-340-773-6459 FAX-340-719-3801 Appointment of Producer Pursuant to Title 22, Section 758, of the Virgin Islands code, the undersigned insurance company hereby applies for authorization for: _________________________________________________________________ (Name of Producer) ________________________________________________________________ (Business Address of Producer / Post Office Box not accepted) _________________________________________________________________ (Kinds of Insurance Producer will write) The above producer 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 ___________ 20___. …
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Government of the United States Virgin Islands Office of the Commissioner – Division of Banking, Insurance and Financial Regulation #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 1131 King Street, Suite 101, Christiansted, V.I. 00820 TEL-340-774-7166 FAX-340-774-5590 TEL-340-773-6459 FAX-340-719-3801 Appointment of Producer Pursuant to Title 22, Section 758, of the Virgin Islands code, the undersigned insurance company hereby applies for authorization for: _________________________________________________________________ (Name of Producer) ________________________________________________________________ (Business Address of Producer / Post Office Box not accepted) _________________________________________________________________ (Kinds of Insurance Producer will write) The above producer 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 ___________ 20___. ________________________________________________________________________ (Please print full legal name of Insurance Company) ________________________________________________________________________ (To be signed by an authorized signatory designated to appoint and/or terminate producers in the United States Virgin Islands) ________________________________________________________________________ (Print Name) _________________________________________________________________ (DO NOT WRITE BELOW THIS LINE) This document is hereby approved and filed in the Office of the Commissioner of Insurance, ____________________________________ ___________________ Commissioner of Insurance Date STATEMENT OF AGREEMENT TO SERVE AS INSURANCE PRODUCER Pursuant to Title 22, Section 758, of the Virgin Islands Code, I hereby agree to serve as producer ___________________________________________________ of (Please print full legal name of Insurance Company) _________________________________________ in and for the Virgin Islands of the (Company’s State of Domicile) 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 781, of the Virgin Islands Code, and will not sign any policies in blank to be issued outside my office. _______________________________________ Signature of Producer Authorized Signatory _______________________________________________________________________ Subscribed and sworn to be fore me this __________day of ____________________, 20___________at________________________________________________________ ____________________________________________ (Notary Public)