USVI Public Records

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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 OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE ORIGINAL INSURANCE APPLICATION FOR RESIDENT OR NON-RESIDENT LICENSE IN THE VIRGIN ISLANDS (ORGANIZATION) 1. LICENSE TYPE: Check box that applies for each category. Applicant must complete a separate application for each license type. a)
Resident
Non-Resident b)
Agent
Broker
Independent-Adjuster
Public-Adjuster
Solicitor
Surplus Line Broker (residents only)
General Agent (residents only)
General Manager (residents only) c)
Life
Health
Property
Casualty
Title
Annuities
Disability
Surety
Variable Annuities
Variable Contracts
Variable Life 2. NAME OF ORGANIZATION: E.I.N: 3. PRINCIPAL BUSINESS ADDRESS: a) PHYSICAL: Street __________________________________________ Apt/Suite # ________ City _____________________________ State _________________ Zip Code ________________ Telephone number ( ) - _______ - ___________ Fax number ( ) - _______ - __________ Email: Website: b) MAILING: Street/P.O. Box _________________________________Office/Suite# _________ City _________________________________ State ________________ Zip Code ___________ 4. Will the organization use a fictitious (DBA) name to transact business?
Yes
No If yes, please indicate such name: 5. Has the organization submitted to the Division of Banking and Insurance, within the last year, an application for which a license has not been issued?
Yes
No If yes, list name under which the application was made, date filed, and license type requested: 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 6. If the Organization holds or has ever held an insurance license, complete the following:
N/A (Attach a separate sheet if necessary) Type of License & License Number State Resident or Nonresident Date License Held From To 7. GENERAL AGENT OR GENERAL MANAGER APPLICANTS (residents only):
N/A List names of 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. 8. RESIDENT OR NON-RESIDENTAGENT APPLICANTS:
N/A a) List the names of the authorized companies licensed in the Virgin Islands which you will represent and from which you have received or will 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. b) Name the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated: ______________________________________________________________________________________ 9. SURPLUS LINES BROKER APPLICANTS:
N/A 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.) 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) Broker Bond Number: ________________________ Expiration Date _____________ Surety Company: ________________________________ 10. RESIDENT OR NONRESIDENT BROKER APPLICANTS:
N/A List all Jurisdictions in which the organization is or has been licensed to do business: STATE TYPE OF LICENSE DATE FROM TO 11. RESIDENT OR NON-RESIDENT BROKER APPLICANTS:
N/A a) List name(s) of authorized companies which the organization represents or through which business is being placed. You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable Broker Bond Number: Expiration Date: Surety Company __________________________________________ c) 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 INDEPENDENT ADJUSTER APPLICANTS:
N/A 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. 13. RESIDENT OR NON-RESIDENT PUBLIC ADJUSTER APPLICANTS: :
N/A Public Adjuster 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 14. List each person who will be authorized to transact insurance business under the license applied for and his/her relationship to the organization. Relationship to the organization must be that of an EMPLOYEE, OFFICER, or PARTNER, as appropriate to the organization type. An Individual license is required for each person named, and a separate application form must be completed and submitted by such person. NAME LAST FIRST MI RELATIONSHIP TO ORGANIZATION 15. CORPORATE APPLICANTS ONLY:
N/A Complete the following and attach a copy of the Articles of Incorporation: (Attach a separate sheet if more space is needed) a) Corporate # ________________________________________ Date Incorporated ___________________________________ State in which incorporated ____________________________ Attach relevant corporate documents b) List each Officer, Director, and Stockholder who owns 10% or more of the corporation’s stock: NAME LAST FIRST MI RESIDENCE SOCAIL SECURITY # % Ownership President Vice President Treasurer Director Director Director Stockholder 16. PARTNERSHIP APPLICANT ONLY: List name and address of all partners and attach the partnership agreement, if any. If no agreement, so state. (Attach a separate sheet if more space is needed.) NAME LAST FIRST MI RESIDENCE SOCAIL SECURITY # % Ownership 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 17. LIMITED LIABILITY COMPANIES ONLY: Complete the following and attach a copy of the Articles of Organization: (Attach a separate sheet if more space is needed) a) LLC # ________________________________________ Date Incorporated ___________________________________ State in which incorporated ____________________________ (Attach relevant corporate documents) c) List each Officer, Director, and Stockholder who owns 10% or more of the corporation’s stock: NAME LAST FIRST MI RESIDENCE SOCAIL SECURITY # % Ownership 18. Is there any person within the organization, other than named in questions (14, 15, 16 and 17), who directs the affairs of the organization
Yes
No If yes, list name, residence address, and social security number of such person(s): NAME LAST FIRST MI RESIDENCE SOCAIL SECURITY # % Ownership 19. 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 17 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, 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 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 20. 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 17?
Yes
No If yes, explain in detail. Attach a separate sheet if needed. 21. 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 17 ever been arrested, charged or convicted of a crime?
Yes
No If yes, explain in detail. Attach a separate sheet if needed. 22. 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 17, been involved in any bankruptcy or receivership proceedings within the past ten years?
Yes
No If yes, explain in detail. Attach a separate sheet if needed. 23. 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 17, been indebted, other than for current accounts, to any insurance company or person for unpaid insurance premium?
Yes
No If yes, explain in detail. Attach a separate sheet if needed. IMPORTANT NOTICES: Failure to fully answer all questions on the 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, 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 but not limited to, the information reported in questions (19),(20), (21) (22) and (23) and any changes in the business operations of the Applicant. If the answer is "YES" to questions (19), (20), (21) (22) and (23), 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. CERTIFICATION OF AUTHORIZED SIGNATORY: 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 this application to denial and may subject the license(s) applied for 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: Name of Organization: By: _________________________________________ _________________________________________ Print Name Title _________________________________________ Signature The following items are needed for licensure: Tax Clearance Letter -------------------------------------------- License or Letter of Certification from State of domicile ---------------------------------------------------------- Broker’s Bond -------------------------------------------------- Surplus Lines’ Bond -------------------------------------------- Public Adjuster’s Bond ---------------------------------------- Articles of Incorporated and Bylaws ----------------------- Original License Fee-------------------------------------------- Appointment Forms & Fee------------------------------------- Resident only Non-resident only Resident & Non-resident only Resident only Resident & Non-resident Resident & Non-resident Resident & Non-resident Resident & Non-resident 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 RESIDENT ORIGINAL FEE BOND Solicitor $300.00 N/A Agent $300.00 N/A Appointment $ 25.00 N/A General Agent $600.00 N/A 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) Appointment $ 25.00 N/A 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: 09/2013) 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 Government of the Unites States Virgin Islands Office of the Commissioner – Division of Banking and Insurance #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 TEL-340-774-7166 FAX 340-774-5590 Appointment of Agent Pursuant to Title 22, Section 753, of the Virgin Islands code, the undersigned insurance company hereby applies for authorization for: _________________________________________________________________ (Name of Agent/Agency) ________________________________________________________________ (Business Address of Agent/Agency. Post Office Box not accepted) _________________________________________________________________ (Kinds of Insurance Agent/Agency 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 ___________ 20___ and expiring on ___________ 20___. ______________________________________________________________________________ (Please print full legal name of Insurance Company) ______________________________________________________________________________ (To be signed by an authorized signatory designated to appoint and/or terminate agents 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 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 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 (Please print full legal name of Insurance Company) _________________________________________ in and for the Virgin Islands of the (Company’s State of Domicile address) 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. _______________________________________ Signature of Agent/Agency’s Authorized Signatory ______________________________________________________________________________ Subscribed and sworn to before me this __________day of ___________________________, 20___________at_______________________________________________________________ ____________________________________________ (Notary Public)