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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 (INDIVIDUAL) 1. LICENSE TYPE: [Check only one box in categories (a) and (b); Applicant must complete a separate application for each license] a)
Agent
Broker
Indep.-Adjuster
Public-Adjuster
Surplus Line Broker
Solicitor
General Agent b)
Life & Health
Property & Casualty
Title
All Lines
Other _____________ c)
Resident
Non-Resident 2. NAME OF APPLICANT: Mr. Mrs. Ms. Miss Last First Middle Name: 3. IDENTIFICATION INFORMATION: S.S.N. Sex:
M
F Date of Birth: Place of Birth: MM/DD/YYYY City, State Email: Website: 4. BUSINESS ADDRESS: (P.O. Box not acceptable) Address Change from last renewal? Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Business Phone No: ( ) - ________ - _____________ Fax Phone No: ( ) - ______ - ______________ 5. RESIDENCE ADDRESS: (P.O. Box not acceptable) Address Change from last renewal? Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Home Phone No: ( ) - _________ - _________________ 6. MAILING ADDRESS:
Business
Residence Address Change from last renewal? Street/P.O. Box _____________________________________ Apt/Suite # ___________________________ City _________________________________ State _______________________ Zip Code ______________ 7. Do you intend to use a fictitious (DBA) name to transact insurance business?
Yes
No If yes, list such name: Name of Business (dba) 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 8. Are you now or have you ever used any name other than shown in (2) or (7)?
Yes
No (If yes, list names, dates, and reasons used.) Name Date Reason 9. LIFE AGENT APPLICANTS ONLY: a) If you intend to act as a Variable Contract Agent, are you registered with the Division of Banking and Insurance?
Yes
No (If yes, provide your BD-A registration number. If no, state the reason why you have not registered.) b) If you intend to act as a Variable Contract Agent, are you registered with NASD?
Yes
No (Provide evidence of same.) 10. RESIDENT AGENT APPLICANTS: List names of authorized companies which you will represent and from which you have received or will receive 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.) Name of Company(ies) licensed in the VI that you will represent. 11. RESIDENT BROKER APPLICANTS: List names of 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.) Name of licensed company(ies) in the VI. Broker Bond Number: Surety Company: 12. SOLICITOR APPLICANTS: Provide the name of the Agent or Agency with which you are appointed. 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 13. NON-RESIDENT AGENT AND BROKER APPLICANTS ONLY: List name(s) of authorized companies that you will be representing or 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.) Name of agency with which you are affiliated with: 14. NON-RESIDENT BROKER APPLICANTS ONLY: Broker Bond Number: Surety Company: 15. SURPLUS LINE BROKER APPLICANTS ONLY: List the names of all “unauthorized insurers” or “surplus lines carries” 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 applicant: (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) Eligible Unauthorized Insurers in the Virgin Islands Broker Bond Number: Surety Company: 16. ADJUSTER APPLICANTS ONLY: If you are an Office Manager, list names of adjusters working directly under your supervision: Public Adjuster Bond Number: Surety Company: 17. INDEPENDENT ADJUSTER APPLICANTS: List Companies with which you are affiliated 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 18. IF YOU NOW HOLD OR HAVE EVER HELD AN INSURANCE LICENSE, COMPLETE THE FOLLOWING: Type of License State Resident Nonresident Date License Held From To 19. LIST YOUR PLACES OF RESIDENCE FOR THE PAST FIVE YEARS: From (MM/YYYY) To (MM/ YYYY) Street City State Postal Code 20. LIST YOUR OCCUPATION (EMPLOYMENT) FOR THE PAST FIVE YEARS TO CURRENT DATE: From (MM/YYYY) To (MM/YYYY) Employer Name Address Duties Performed 21. HAVE YOU 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 fully on a separate sheet) 22. ARE THERE CURRENTLY ANY DISCIPLINARY ACTIONS PENDING AGAINST YOU?
Yes
No (If yes, please explain fully on a separate sheet) 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 23. HAVE YOU EVER BEEN ARRESTED, CHARGED OR CONVICTED OF A CRIME?
Yes
No (If yes, attach a detailed statement, signed by you, of the events which led to the charges including the dates and places. If the matter was heard in court, attach copies Certified by the Court, of the Criminal Complaint and the Sentencing Order showing the final judgment.) 24. HAVE YOU BEEN INDEBTED, OTHER THAN FOR CURRENT ACCOUNTS, TO ANY INSURANCE COMPANY OR PERSON FOR UNPAID INSURANCE PREMIUMS OR RETURN PREMIUMS?
Yes
No (If yes, please explain fully on a separate sheet) 25. HAVE YOU, IN THE PAST TEN YEARS, EVER BEEN INVOLVED IN ANY BANKRUPTCY OR RECEIVERSHIP PROCEEDINGS?
Yes
No (If yes, please explain fully on a separate sheet) **If the answer is "YES" to questions (21), (22), (23) (24) and (25), 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. 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 21, 22, 23, 24 and 25 and any changes in the business operations of the Applicant. The following items are needed for licensure: 1) Broker’s Bond * 2) Surplus Lines’ Bond * 3) Public Adjuster’s Bond * 4) Three Letters of Recommendation** 5) Written Examination** 6) Original License Fee 7) Appointment Forms*** 8) Appointment Fee**** 9) Identification (Gov’t issued, i.e.: Driver’s license, Passport, Vote’s Registration Card, etc.) *Brokers, Public Adjusters and Surplus Lines Brokers only ** Non-Resident Adjusters and All Residents only ***FOR Agents, Solicitors and General Agent only ****For Agent and Solicitors only RESIDENT ORIGINAL FEE BOND Solicitor $300.00 N/A Agent $300.00 N/A Appointment Fee (Agent/Solicitor) $ 25.00 N/A General Agent $600.00 N/A Resident Broker $400.00 10,000.00 Surplus Line Broker $400.00 10,000.00 Adjuster (Independent/Public) $300.00 5,000.00 (Public Only) NON-RESIDENT ORIGINAL FEE BOND Agent $600.00 N/A Broker $800.00 10,000.00 Adjuster (independent/Public) $300.00 5,000.00 (Public Only) (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 APPLICANT’S CERTIFICATION: 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 my application to denial and may subject my license(s) 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 _______________________ ______________________________________ Signature ________________________________________ Print Name FOR OFFICE USE ONLY Receipt Number: _______________________ Date: __________________ Amount: $_________________ (REV: 10/07)