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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 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 ORIGINAL 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: 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. 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: (Attach a separate sheet if necessary) Type of License & License Number State Resident or Nonresident Date License Held From To 7. RESIDENT AGENT APPLICANTS (Including general agent or manager): 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 BROKER APPLICANTS: a) List the names of the 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) Broker Bond Number: Surety Company: 9. SURPLUS LINES BROKER APPLICANTS: 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: 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 10. NONRESIDENT AGENT/BROKER APPLICANTS: List all Jurisdictions in which the organization is or has been licensed to do business: STATE TYPE OF LICENSE DATE FROM TO 11. NON-RESIDENT AGENT/BROKER APPLICANTS: 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.) 12. NONRESIDENT BROKER APPLICANTS: Broker Bond Number: Surety Company: 13. 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.) 14. PUBLIC ADJUSTER APPLICANTS: Public Adjuster Bond Number: Surety Company: 15. 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 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 16. CORPORATE APPLICANTS ONLY: 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 SOCIAL SECURITY # % Ownership President Vice President Treasurer Director Director Director Stockholder 17. 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 SOCIAL SECURITY # % Ownership 18. 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) 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) List each Officer, Director, and Stockholder who owns 10% or more of the corporation’s stock: NAME LAST FIRST MI RESIDENCE SOCIAL SECURITY # % Ownership 19. Is there any person within the organization, other than named in questions (15, 16, 17 and 18), 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 SOCIAL SECURITY # % Ownership 20. 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 18 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.): 21. 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 18?
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 • Telephone: (340) 773-6459 • Fax: (340)-719-3801 22. 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 18 ever been arrested, charged or convicted of a crime?
Yes
No (If yes, please explain in detail. Attach a separate sheet if needed.): 23. 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 18, 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.): 24. 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 18, 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 (20), (21), (22) (23) and (24), 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 NOTICES: Failure to fully answer all questions on application 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 (20),(21), (22) (23) and (24) and any changes in the business operations of the Applicant. The following items are also needed for licensure of Brokers, Public Adjusters and Surplus Lines Brokers: 1) Broker’s Bond 2) Surplus Lines’ Bond 3) Public Adjuster’s Bond 4) Fee Information for Original 5) Identification (Gov’t issued, i.e.: Driver’s license, Passport, Vote’s Registration Card, etc.) All checks and money orders must be made payable to Government of the U.S. Virgin Islands. 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 Agent $300.00 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) Solicitor 300.00 N/A General Agent 600.00 N/A NON-RESIDENT ORIGINAL FEE BOND Agent 600.00 N/A Broker 800.00 10,000.00 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 _________________________________________ Signature _________________________________________ Title FOR OFFICE USE ONLY Receipt Number: _______________________ Date: __________________ Amount: $_________________ (REV: 10/07)