USVI Public Records

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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 OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE RENEWAL INSURANCE APPLICATION FOR RESIDENT OR NON-RESIDENT INSURANCE LICENSE (INDIVIDUAL) 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)
General Manager (residents only) c)
Life
Health
Property
Casualty
Title
Annuities
Disability
Surety
Variable Annuities
Variable Contracts
Variable Life 2. NAME OF APPLICANT: □ Mr. □Mrs. □ Ms Last _________________________ First __________________________ Middle Name _____________ 3. IDENTIFICATION INFORMATION: S.S.N. ____________________________ Sex: □ M □ F 4. BUSINESS PHYSICAL ADDRESS: □ Address Change from last renewal? Street __________________________________ Apt/Suite # ____________________________ City ____________________________ State _______________________ Zip Code __________ Business Phone Number: _____________________ Fax Phone Number: ___________________________ E-mail Address: _________________________________ Website: __________________________________ 5. RESIDENCE ADDRESS: (P.O. Box not acceptable) □ Address Change from last renewal? Street _____________________________________ Apt/Suite # _________________________ City ____________________________ State _______________________ Zip Code __________ Home Phone Number: __________________________ E-mail Address _____________________________ 6. MAILING ADDRESS: □ Business □ Residence □ Address Change from last renewal? Street/P.O. Box _________________________________ Apt/Suite # ______________________ City _____________________________ State _______________________ Zip Code _________ 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 7. Have you been arrested, charged or convicted of a crime since your last renewal? □ Yes □ No If yes, explain in detail. Attach a separate sheet if necessary. _________________________________________________________________________________________ 8. Have you, since the issuance of your last license, had any professional, vocational or business license denied, suspended, revoked or restricted or a fine imposed by any licensing authority or withdrawn any application for or surrendered any such license to avoid disciplinary action? □ Yes □ No If yes, explain in detail. Attach a separate sheet if necessary. _________________________________________________________________________________________ __________________________________________________________________________________________ 9. Are there currently any disciplinary actions pending against you? □ Yes □ No If yes, explain in detail. Attach a separate sheet if necessary. __________________________________________________________________________________________ __________________________________________________________________________________________ 10. Have you, since the issuance of your last license, been indebted, other than for current accounts, to any insurance company or person for unpaid insurance premiums or return premiums? □ Yes □ No If yes, explain in detail. Attach a separate sheet if necessary. __________________________________________________________________________________________ __________________________________________________________________________________________ 11. Have you, since the issuance of your last license, been involved in any bankruptcy or receivership proceedings? □ Yes □ No If yes, explain in detail. Attach a separate sheet if necessary. __________________________________________________________________________________ __________________________________________________________________________________ 12. GENERAL AGENT OR GENERAL MANAGER APPLICANTS ONLY (residents only): □ N/A a) List the name(s) of the company or companies licensed in the Virgin Islands, that you represent 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 in the U.S. Mainland or 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 13. RESIDENT OR NONRESIDENT AGENT/SOLICITORS APPLICANTS: □ N/A a) List name(s) of companies/agencies licensed in the Virgin Islands through which you represent and from 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 Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated: ____________________________________________________________________________________________________________________________ 14. RESIDENT OR NON-RESIDENT BROKER APPLICANTS: □ N/A a) List the name(s) of the company or companies licensed in the Virgin Islands, through which you 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) Name of Agency on the U.S. Mainland or the U.S Virgin Islands through which you are affiliated: _________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ c) Broker Bond Number: __________________________ Expiration Date ______________ Surety Company ________________________ 15. 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) Name of Agency in the U.S. Virgin Islands through which you are affiliated: _______________________________________________________________________________________________________________________ c) Broker Bond Number: __________________________ Expiration Date ______________ Surety Company ________________________ 16. RESIDENT INDEPENDENT ADJUSTER APPLICANTS ONLY: □ N/A If you are an Office Manager, list names of adjusters working directly under your supervision: ____________________________________ ______________________________________ ____________________________________ ______________________________________ 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 17. RESIDENT OR NON-RESIDENT INDEPENDENT ADJUSTER APPLICANTS: □ 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. ______________________________________________________________________________________ ______________________________________________________________________________________ 18. RESIDENT OR NON-RESIDENT PUBLIC ADJUSTER APPLICANTS: □ N/A Public Adjuster Bond Number: ___________________ Expiration Date ______________ Surety Company____________________ 19. RESIDENT OR NON-RESIDENT LIFE AGENT APPLICANTS ONLY: □ N/A a) If you are acting 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 are acting as a Variable Contract Agent, are you registered with NASD? □ Yes □ No 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 7, 8, 9, 10 and 11, and any changes in the business operations of the Applicant. If the answer is "YES" to questions 7, 8, 9, 10 and 11, 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. NAME: _________________________________ DATE: __________________________ Print Signature: _______________________________ Title: ___________________________________ 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 The following items are needed for Renewal: 1) Renewal Fee Resident and Non-resident 2) Broker’s Bond Resident and Non-resident 3) Surplus Lines’ Bond Resident only 4) Public Adjuster’s Bond Resident and Non-resident 5) Tax Clearance Letter Resident only 6) License or Letter of Certification from State of Domicile Non-resident only 7) Appointment of Agent Document (If not on file or expired) Resident and Non-resident 8) Appointment of Agent Fee Resident and Non-resident Make check or money order payable to the Government of the U.S. Virgin Islands. 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 FOR OFFICE USE ONLY Receipt Number: _______________________ Date: __________________ Amount: $___________ (REV: 09/2013)