USVI Public Records

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THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION M E M O R A N D U M TO: All Foreign, Domestic and Alien Insurance Companies, Mutual Nonprofit Benefit Societies and Rating Organizations Authorized to Conduct Business in the U.S. Virgin Islands FROM: The Division of Banking, Insurance and Financial Regulation RE: Certificate of Authority, Certificate of Licensure or Permit Renewal The company’s License will expire on December 31st of each year. Please complete the Application for Renewal and submit it along with the required renewal fee as followed: Certificate of Authority or Certificate of Licensure Renewal --------- $600.00 Or Permit Renewal ------------------------------- $ 25.00 A late penalty of $50.00 will be assessed against any renewal application and payment received after January 15th of the following year. Be reminded that the company is under a continuing obligation to satisfy all requirements listed in your conditional letter previously received in order to remain in good standing with the Division. Should you need any additional information, please contact the Division at 340-774-7166. Please direct all mailings to: Office of the Lieutenant Governor Division of Banking, Insurance and Financial Regulation #5049 Kongens Gade Charlotte Amalie, St. Thomas, USVI 00802-6487 Office of the Lt. Governor λDivision of Banking, Insurance and Financial Regulation Kongens Gade #5049λSt. Thomas, U.S. Virgin Islands λ00802 Phone (340) -774-7166 λFax (340)-774-9458 2 TERRITORY OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION ********************** APPLICATION FOR RENEWAL OF CERTIFICATE OF AUTHORITY CERTIFICATE OF LICENSURE or PERMIT 1. Name of Company ___________________________________________________ (Please indicate Company’s full legal name) Company’s President_________________________________________________ E-Mail:__________________________ Telephone No._____________________ Company’s FEIN No.________________________ NAIC No.________________ State of Incorporation__________________ Date of Incorporation_____________ Business Address ____________________________________________________ ____________________________________________________ Telephone No._____________________________ Fax No.___________________ Statutory Home Office Address _________________________________________ _________________________________________ Telephone No._____________________________ Fax No.___________________ Main Administrative Office Address _____________________________________ _____________________________________ Telephone No._____________________________ Fax No.___________________ Mailing Address: ____________________________________________________ ____________________________________________________ Office of the Lt. Governor λDivision of Banking, Insurance and Financial Regulation Kongens Gade #5049λSt. Thomas, U.S. Virgin Islands λ00802 Phone (340) -774-7166 λFax (340)-774-9458 3 2. Domicile Type: □Domestic □Foreign □Alien 3. Company Type: □Life □Health □Property □Casualty □Title □Surety □All Lines □ Other _____________________________________ 4. Organization Type: □Association □Corporation □Mutual □Non-profit □ 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_____________________________________________________________ 7. Contact Person for Licensure and related filings Name/Title: _________________________________________________________ Mailing Address: _____________________________________________________ ______________________________________________________ Telephone No. ________________________Fax No._________________________ E-Mail______________________________________________________________ Office of the Lt. Governor λDivision of Banking, Insurance and Financial Regulation Kongens Gade #5049λSt. Thomas, U.S. Virgin Islands λ00802 Phone (340) -774-7166 λFax (340)-774-9458 4 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______________________________________________________________ 11. Authorized Signatory to Appoint and Terminate Agents in the U.S. Virgin Islands Print Name Signature ________________________________ ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ Office of the Lt. Governor λDivision of Banking, Insurance and Financial Regulation Kongens Gade #5049λSt. Thomas, U.S. Virgin Islands λ00802 Phone (340) -774-7166 λFax (340)-774-9458 5 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:______________________________________________________________ IMPORTANT NOTICE: The Company must promptly notify the Division of Banking, Insurance and Financial Regulation of any changes in the information reported on this application. PERSON COMPLETING THIS APPLICATION: Name______________________________________ Date_____________________ (Please Print) Signature ______________________________________________________________ Relationship to Company _________________________________________________ E-mail:________________________ Telephone No.____________________________