OFFICE OF THE LIEUTENANT GOVERNOR
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 INDIVIDUAL REGISTRATION FORM NONRESIDENT INDEPENDENT ADJUSTER 1. NAME OF APPLICANT: Mr. Mrs. Ms. Miss Last First Middle Name: 2. IDENTIFICATION INFORMATION: S.S.N. Sex: M F Date of Birth: Place of Birth: MM/DD/YYYY City, State Email: Website: 3. BUSINESS NAME AND ADDRESS: Name: _____________________________(P.O. Box not acceptable) Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Business Phone No: ( ) - ________ - _____________ Fax Phone No: ( ) - ______ - ______________ 4. PHYSICAL ADDRESS IN STATE OF DOMICILE: (P.O. …
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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 INDIVIDUAL REGISTRATION FORM NONRESIDENT INDEPENDENT ADJUSTER 1. NAME OF APPLICANT: Mr. Mrs. Ms. Miss Last First Middle Name: 2. IDENTIFICATION INFORMATION: S.S.N. Sex: M F Date of Birth: Place of Birth: MM/DD/YYYY City, State Email: Website: 3. BUSINESS NAME AND ADDRESS: Name: _____________________________(P.O. Box not acceptable) Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Business Phone No: ( ) - ________ - _____________ Fax Phone No: ( ) - ______ - ______________ 4. PHYSICAL ADDRESS IN STATE OF DOMICILE: (P.O. Box not acceptable) Street ____________________________________________ Apt/Suite # ____________________________ City _________________________________ State _______________________ Zip Code _______________ Phone No: ( ) - _________ - _________________ 5. PHYSICAL ADDRESS WHILE IN THE VIRGIN ISLANDS: Street _____________________________________ Apt/Suite # ___________________________ City _________________________________ State _______________________ Zip Code ______________ Phone No: ( ) - _________ - _________________ BY SIGNATURE HERETO I hereby certify that the information provided in this application is true and correct. Date:_____________ ________________________________ Applicant's Signature Subscribed and Sworn to before me this ____ day of ___________________, 20___. ________________________________ Notary Public Commission Expires:_______________ Commission Number:_______________ NOTE: You are required to attach a copy of your adjuster's license from your state of domicile along with a copy of your picture identification.