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5049 KONGENS GADE i ST. THOMAS, VI 00802 iPHONE: (340) 774-7166 iFAX: (340) 774-9458 1131 KING STREET, SUITE 101 i ST. CROIX, VI 00820 iPHONE: (340) 773-6459 i FAX: (340) 719-3801 REQUIREMENTS FOR RENEWAL OF CERTIFICATE OF REGISTRATION (Purchasing Group) DOCUMENTS TO BE FILED
1. A completed renewal registration application.
2. A copy if its Certificate of Registration or license authorizing it to transact insurance business of this nature, certified by the State of domicile.
3. The Group’s loss exposure and aggregate exposure.
4. A Renewal fee in the sum of $600.00 made payable to the Government of the Virgin Islands. 2 KONGENS GADE NO. 18 i ST. THOMAS, VI 00802 iPHONE: (340) 774-7166 iFAX: (340) 774-9458 1131 KING STREET, SUITE 101 i ST. CROIX, VI 00820 iPHONE: (340) 773-6459 i FAX: (340) 719-3801 TERRITORY OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE RENEWAL REGISTRATION PURCHASING GROUP (All information should be typed) 1. List the exact name of the Purchasing Group: 2. (a)The Purchasing Group is domiciled in the State of: (b)Address: ________________________________________________________ 3. (a) List the complete physical address of the Purchasing Group: (b) List the complete mailing address of the Purchasing Group: 4. (a) List the name(s), position, address(es), telephone number(s) and facsimile number(s) of the principal staff person or officer of the Purchasing Group who has knowledge of its insurance program, including membership criteria, coverage, and key personnel of the group’s administrator and insurance carrier. (Attach additional pages if necessary) 3 KONGENS GADE NO. 18 i ST. THOMAS, VI 00802 iPHONE: (340) 774-7166 iFAX: (340) 774-9458 1131 KING STREET, SUITE 101 i ST. CROIX, VI 00820 iPHONE: (340) 773-6459 i FAX: (340) 719-3801 NAME POSITION ADDRESS TELEPHONE & FACSIMILE 5. (a) List the name(s), address(es), telephone number(s) and facsimile number(s) of the firm that acts as the administrator of the Purchasing Group, and the name of the principal account executive responsible for the group’s insurance program. (If none, answer “none”). NAME ADDRESS TELEPHONE & FACSIMILE 6. (a) List the name(s), position, address(es), telephone number(s) and facsimile number(s) of the principal agent or broker responsible for the sale or purchase of the group’s liability insurance: (If none, answer “none”.) NAME POSITION ADDRESS TELEPHONE & FACSIMILE 4 KONGENS GADE NO. 18 i ST. THOMAS, VI 00802 iPHONE: (340) 774-7166 iFAX: (340) 774-9458 1131 KING STREET, SUITE 101 i ST. CROIX, VI 00820 iPHONE: (340) 773-6459 i FAX: (340) 719-3801 7. a) List the names, occupations, addresses, telephone numbers and facsimile numbers of the principal officers and directors of the Purchasing Group: (Attach additional pages if necessary) NAME OCCUPATION ADDRESS TELEPHON & FACSIMILE 8. The Purchasing Group purchases such liability insurance only for its members and only to cover their similar or related exposure, as described in item (9) below. (Y/N) ______. 9. The Purchasing Group currently purchases and intends to purchase the following lines and classifications of liability insurance: 5 KONGENS GADE NO. 18 i ST. THOMAS, VI 00802 iPHONE: (340) 774-7166 iFAX: (340) 774-9458 1131 KING STREET, SUITE 101 i ST. CROIX, VI 00820 iPHONE: (340) 773-6459 i FAX: (340) 719-3801 10. The Purchasing Group intends to purchase the liability insurance described in item 9 above from the following insurance company or companies. Give full name of company, state of domicile and FEIN: FULL NAME OF CO. STAE OF DOMICILE FEIN 11. List the name and address of the licensed agent or broker through whom current purchases have been made and future purchases will be made. Complete this item only if the purchase of insurance is or will be made from a surplus lines insurer, rather than from a licensed insurer. 12. Has any person transacting business on behalf of this Purchasing Group ever: (A) been arrested, indicted and convicted of felony, or has a felony charge currently pending against any such person? (Y/N)______ (B) had been denied any application for a professional, vocational or business license? (Y/N)______ (C) had suspended or revoked any such license? (Y/N)______ (D) had withdrawn or surrendered any such application or license to avoid potential disciplinary action against licensee? (Y/N) _______ If the answer to any part of this question is yes, attach a supplementary statement explaining in full each such occurrence. 6 KONGENS GADE NO. 18 i ST. THOMAS, VI 00802 iPHONE: (340) 774-7166 iFAX: (340) 774-9458 1131 KING STREET, SUITE 101 i ST. CROIX, VI 00820 iPHONE: (340) 773-6459 i FAX: (340) 719-3801 13. The Purchasing Group has designated the Virgin Islands Insurance Commissioner to be its agent solely for the purpose of receiving service of legal documents or process. (Y/N)______ Attach to this application is a current Certificate of Good Standing from the group’s state of domicile. Enclosed is a renewal fee in the sum of $600 made payable to the Government of the Virgin Islands. We do hereby swear and affirm that the aforementioned statements and information are true and correct. _________________________________ President or Chief Executive Officer _________________________________ Secretary Subscribed and sworn before me this __________ day of _________________, 20_____. _________________________________ Notary Public State of: __________________________ My Commission Expires: _______________