TERRITORY OF THE UNITED STATES VIRGIN ISLANDS
TERRITORY OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE ************** APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY 1. Name of Company ___________________________________________________ (Please indicate company’s full legal name) Physical Address ____________________________________________________ ____________________________________________________ Mailing Address: ____________________________________________________ ____________________________________________________ Telephone No. ____________________________ Fax No. __________________ 2. Company’s FEIN Number ______________________________________________ 3. Type of Company: □Domestic □Foreign □Alien 4. Lines of Insurance: □ Life □Health □Property □Casualty □ Title □ All Lines □ Other _________________________ 5. …
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TERRITORY OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE ************** APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY 1. Name of Company ___________________________________________________ (Please indicate company’s full legal name) Physical Address ____________________________________________________ ____________________________________________________ Mailing Address: ____________________________________________________ ____________________________________________________ Telephone No. ____________________________ Fax No. __________________ 2. Company’s FEIN Number ______________________________________________ 3. Type of Company: □Domestic □Foreign □Alien 4. Lines of Insurance: □ Life □Health □Property □Casualty □ Title □ All Lines □ 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 Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802 Phone (340) -774-7166 Fax (340)-774-9458 2 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 Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802 Phone (340) -774-7166 Fax (340)-774-9458 3 11. Authorized Signatory to Appoint and Terminate Agents in the U.S. Virgin Islands Name (Print) 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:______________________________________________________________ Office of the Lt. Governor Division of Banking & Insurance Kongens Gade #5049St. Thomas, U.S. Virgin Islands 00802 Phone (340) -774-7166 Fax (340)-774-9458 4 IMPORTANT NOTICE: The company must promptly notify the Division of Banking and Insurance of any changes in the information reported on this application. PERSON COMPLETING THIS APPLICATION: Name______________________________________ Date_____________________ (Please Print) Signature ______________________________________________________________ Relationship to Company _________________________________________________