USVI Public Records

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G Virgin Islands Office of the Lieutenant Governor Division of Banking and Insurance Kongens Gade No. 18, Charlotte Amalie, St. Thomas, USVI, 00802 ¢ (340) 774-7166 * Fax (340) 774-9458 Checklist of Documents And/Or Information Required Application for a Third Party Administrator 1. The completed Application (form enclosed). 2. A copy of the applicant’s basic organizational documents, which shall include articles of incorporation, articles of association, partnership agreement, management agreement, trust agreement or other documents governing the operation of the applicant that are applicable to the applicant’s form of business organization. 3. Acopy of the executed bylaws, rules and regulations, or other documents relating to the operation of the applicant’s internal affairs. 4. A list of the names, addresses and official positions of the persons responsible for the conduct of the affairs of the applicant, including, but not limited to: a. the members of the board of directors, executive or other governing board or committee; b. the principal officers or partners; c. shareholders owning or having the right to acquire 10% or more of the voting securities of the corporation or partnership interest of a partnership, or equity interest, in the case of another form of business organization; and d. any person or entity who has loaned funds to the applicant for the operation of the business. 5. A fully completed and notarized Biographical Affidavit for each of those persons identified in response four (4) above (form enclosed or NAIC form). 6. A statement of any criminal convictions and civil, regulatory or enforcement action, including actions related to professional licensing, taken or pending against any principal officer or owner of the applicant; and the relationship with any other business entity, including a parent corporation. 9. 10. . A statement of the sources of working capital and any other sources of funding; . A description of the provision of contingencies that enable the applicant to perform the work for which it has contracted; . A list of the benefit payers under contract with the applicant and a copy of the standard contract or contracts used by the applicant in the course of business; . A list of the subcontractors under contract with the applicant and a copy of the standard contract or contracts used by the applicant in the course of business with subcontractors; . If applicable, a list of reinsurers with whom the applicant does business and copies of the contract or contracts used by the applicant in the course of business with reinsurers; . A list of all administrative, civil or criminal actions and proceedings to which the applicant, or any of its affiliates have been subject and the resolution of those actions and proceedings. Ifa license, certificate or other authority to operate has been refused, suspended or revoked by any jurisdiction, the applicant shall provide a copy of any orders, proceedings and determinations relating thereto; . A resolution, duly executed by the applicant, appointing the Commissioner and his successor in office as the true and lawful agent of the applicant in and for the Virgin Islands upon whom all lawful process in any legal action, or proceeding against the organization on a cause of action arising in this territory, may be served (form enclosed); An unrefundable application fee of $100.00; A license fee of $650.00.