USVI Public Records

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1 Government of the Unites States Virgin Islands Office of the Commissioner – 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 APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY CERTIFICATE OF LICENSURE or PERMIT 1. Name of Company ___________________________________________________ (Please indicate Company’s full legal name) Company’s President_________________________________________________ E-Mail:__________________________ Telephone No._____________________ Company’s FEIN No.________________________ NAIC No.________________ State of Incorporation__________________ Date of Incorporation_____________ Business Address ____________________________________________________ ____________________________________________________ Telephone No._____________________________ Fax No.___________________ Statutory Home Office Address _________________________________________ _________________________________________ Telephone No._____________________________ Fax No.___________________ Main Administrative Office Address _____________________________________ _____________________________________ Telephone No._____________________________ Fax No.___________________ Mailing Address: ____________________________________________________ ____________________________________________________ Office of the Lt. Governor Division of Banking, Insurance and Financial Regulation Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802 Phone (340) -774-7166 Fax (340)-774-9458 2. Domicile Type: □Domestic □Foreign □Alien 3. Company Type: □Life □Health □Property □Casualty □Title □Surety □All Lines □ Other _____________________________________ In addition to company type, please list types of insurance e.g. auto, home, renters, health (group or individual), long-term care, life (whole, term or universal), travel, liability, medical malpractice, commercial, marine and credit: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4. Organization Type: □Association □Corporation □Mutual □Non-profit □ Other ___________________________________ 5. Contact Person for Premium Tax Quarterly Filings Name/Title: _________________________________________________________ Mailing Address: ____________________________________________________ ______________________________________________________ Telephone No. _________________________Fax No.________________________ E-Mail _____________________________________________________________ 6. Contact Person for Annual Statement and Audited Financial Report Filing Name/Title: _________________________________________________________ Mailing Address: ____________________________________________________ _____________________________________________________ Telephone No.________________________ Fax No.________________________ E-Mail_____________________________________________________________ Office of the Lt. Governor Division of Banking, Insurance and Financial Regulation Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802 Phone (340) -774-7166 Fax (340)-774-9458 7. Contact Person for Licensure and related filings Name/Title: _________________________________________________________ Mailing Address: _____________________________________________________ ______________________________________________________ Telephone No. ________________________Fax No._________________________ E-Mail______________________________________________________________ 8. Contact Person for Policy Forms Name/Title: __________________________________________________________ Mailing Address: ______________________________________________________ _______________________________________________________ Telephone No. ________________________ Fax No.________________________ E-Mail______________________________________________________________ 9. Contact Person for Consumer Complaints Name/Title: __________________________________________________________ Mailing Address: ______________________________________________________ _______________________________________________________ Telephone No. __________________________Fax No._______________________ E-Mail:______________________________________________________________ 10. Contact Person – Company’s Statutory Deposit Name/Title: __________________________________________________________ Mailing Address:______________________________________________________ _______________________________________________________ Telephone No. ___________________________Fax No.______________________ E-Mail______________________________________________________________ Office of the Lt. Governor Division of Banking, Insurance and Financial Regulation Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802 Phone (340) -774-7166 Fax (340)-774-9458 11. Authorized Signatory to Appoint and Terminate Agents in the U.S. Virgin Islands Print Name Signature _______________________________ ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ 12. List Name of Agent(s)/Agency currently representing Company in the U.S. Virgin Islands for marketing of products: ________________________________ _________________________________ ________________________________ ________________________________ 13. General Agent resident in the U.S. Virgin Islands to appoint subagents: ________________________________ _________________________________ ________________________________ _________________________________ 14. Contact Person for company’s participation in V.I. Guaranty Fund (if applicable): Name/Title:___________________________________________________________ Mailing Address:_______________________________________________________ ______________________________________________________ Telephone No. ___________________________ Fax No.______________________ E-Mail:______________________________________________________________ IMPORTANT NOTICE: The Company must promptly notify the Division of Banking, Insurance and Financial Regulation of any changes in the information reported on this application. PERSON COMPLETING THIS APPLICATION: Name______________________________________ Date_____________________ (Please Print) Signature ______________________________________________________________ Relationship to Company _________________________________________________ Email:_______________________________ Telephone;________________________