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OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE RENEWAL APPLICATION FOR RESIDENT OR NON-RESIDENT INSURANCE LICENSE (ORGANIZATION) Please Print or Type 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 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: □ Address Change from last renewal? Physical: Street ________________________________________ Apt/Suite # _____________ City ____________________________ State _______________________ Zip Code __________ Business Phone Number: _____________________ Fax Phone Number: ___________________________ E-mail: _____________________ Website: _______________________ Mailing: P.O. Box/Street __________________________________ Apt/Suite # ______________ City ____________________________ State _______________________ Zip Code __________ Business Phone Number: _____________________ Fax Phone Number: ___________________________ 4. GENERAL AGENT OR GENERAL MANAGER APPLICANTS: □N/A a) List the name(s) of the company or companies licensed in the Virgin Islands, that the organization represents or through 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. __________________________________________________________________________________________ __________________________________________________________________________________________ 5049 Kongens Gade, St. Thomas, Virgin Islands 00802 • Telephone (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, Virgin Islands 00820 • Telephone (340) 773-6459 • Fax: (340) 719-3801 b) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated: __________________________________________________________________________________________ 5. RESIDENT OR NON-RESIDENT AGENT APPLICANTS: □N/A a) List the name(s) of the company or companies licensed in the Virgin Islands, that the organization represents or through 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. __________________________________________________________________________________________ __________________________________________________________________________________________ b) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated: __________________________________________________________________________________________ 6. RESIDENT OR NON-RESIDENT BROKER APPLICANTS: □N/A a) List the name(s) of the company or companies licensed in the Virgin Islands, that 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. __________________________________________________________________________________________ __________________________________________________________________________________________ b) Broker Bond Number:________________________ Surety Company___________________________ c) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated: __________________________________________________________________________________________ 7. SURPLUS LINE BROKER APPLICANTS ONLY: □N/A a) List the name(s) of all “unauthorized insurers” or “surplus lines carriers” that are eligible to conduct surplus lines business in the Virgin Islands with which arrangements have been made to accept or which are considering the acceptance of surplus lines business offered by the applicant. 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:________________________ Expiration Date ______________ Surety Company___________________________ c) Name of the Agency in the U.S. Virgin Islands through which you are affiliated: __________________________________________________________________________________________ 5049 Kongens Gade, St. Thomas, Virgin Islands 00802 • Telephone (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, Virgin Islands 00820 • Telephone (340) 773-6459 • Fax: (340) 719-3801 8. RESIDENT OR NON-RESIDENT INDEPENDENT ADJUSTER APPLICATIONS: □N/A List the names(s) of the company or companies licensed in the Virgin Islands through 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. __________________________________________________________________________________________ __________________________________________________________________________________________ 9. RESIDENT OR NON-RESIDENT PUBLIC ADJUSTER APPLICANTS: □N/A Broker Bond Number:________________________ Surety Company___________________________ 10. Pursuant to Title 22, Section 754(b), Virgin Islands Code, list the names of each individual authorized to exercise to powers conferred by the license applied for: LAST FIRST MIDDLE INITIAL __________________________________________________________________________________________ __________________________________________________________________________________________ 11. Has the organization or have any of its members, managers, partners, principal, 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 impose 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 on a separate sheet. 12. 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 on a separate sheet. 13. 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 on a separate sheet. 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 nine (9), been involved in any bankruptcy or receivership proceedings within the past ten years? □ Yes □ No If yes, please explain in detail on a separate sheet. 15. 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 nine (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 on a separate sheet. 5049 Kongens Gade, St. Thomas, Virgin Islands 00802 • Telephone (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, Virgin Islands 00820 • Telephone (340) 773-6459 • Fax: (340) 719-3801 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 11, 12, 13, 14 and 15, and any changes in the business operations of the Applicant. If the answer is "YES" to questions 11, 12, 13, 14 and 15, please attach a notarized statement 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. Failure to fully answer all questions on application and non-submission of the required documents will result in the application being returned to applicant. Also, please note that the processing time for the application begins when all the aforementioned information are received. Please enclose the appropriate renewal fee(s) with application on or before December 31st. Any application received after January 15th will be assessed a late penalty of $50.00. __________________________________ DATE: __________________ Signature _________________________________ __________________________________ Print Name Title The following items are needed for Renewal: 1) Renewal Fee Resident and Non-resident 2) Broker’s Bond Resident and Non-resident 2) Surplus Lines’ Bond Resident only 3) Public Adjuster’s Bond Resident and Non-resident 4) Tax Clearance Letter Resident only 5) License or Letter of Certification from State of Domicile Non-resident only 6) Appointment of Agent Document (If not on file or expired) Resident and Non-resident 7) Appointment of Agent Fee Resident and Non-resident 5049 Kongens Gade, St. Thomas, Virgin Islands 00802 • Telephone (340) 774-7166 • Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, Virgin Islands 00820 • Telephone (340) 773-6459 • Fax: (340) 719-3801 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 Appointment Fee $ 25.00 NONRESIDENT RENEWAL FEE BOND Agent $350.00 N/A Broker $350.00 $10,000.00 Adjuster (Independent/Public) $150.00 $5,000.00 (Public Only Appointment Fee $ 25.00 _____ Make check or money order payable to the Government of the U.S. Virgin Islands. ___________________________________________________________________________ FOR OFFICE USE ONLY Receipt Number: _______________________ Date: _______________ Amount: _______________ (REV: 09/2012)