Appointment of Agent
Appointment of Agent ~ײ~ COMMISSIONER OF INSURANCE CHARLOTTE AMALIE ST. THOMAS, VIRGIN ISLANDS Dear Sir: Pursuant to Title 22, Section 753, of the Virgin Islands code, the undersigned insurance company hereby applies for authorization for: _________________________________________________________________ (NAME OF AGENT) ________________________________________________________________ (BUSINESS ADDRESS OF AGENT) _________________________________________________________________ (KINDS OF INSURANCE AGENT WILL WRITE) The above agent is hereby authorized to solicit, accept applications, write, issue, deliver and place policies or contracts of direct insurance upon risks located within the Virgin Islands, effective__________________________ DATE _______________________________________________________________ (NAME OF INSURANCE COMPANY) ________________________________________________________________ (TO BE SIGNED BY A RESPONSIBLE OFFICER OF THE COMPANY) ________________________________________________________________ (PRINT NAME) (DO NOT WRITE BELOW THIS LINE) _____________________________ …
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Appointment of Agent ~ײ~ COMMISSIONER OF INSURANCE CHARLOTTE AMALIE ST. THOMAS, VIRGIN ISLANDS Dear Sir: Pursuant to Title 22, Section 753, of the Virgin Islands code, the undersigned insurance company hereby applies for authorization for: _________________________________________________________________ (NAME OF AGENT) ________________________________________________________________ (BUSINESS ADDRESS OF AGENT) _________________________________________________________________ (KINDS OF INSURANCE AGENT WILL WRITE) The above agent is hereby authorized to solicit, accept applications, write, issue, deliver and place policies or contracts of direct insurance upon risks located within the Virgin Islands, effective__________________________ DATE _______________________________________________________________ (NAME OF INSURANCE COMPANY) ________________________________________________________________ (TO BE SIGNED BY A RESPONSIBLE OFFICER OF THE COMPANY) ________________________________________________________________ (PRINT NAME) (DO NOT WRITE BELOW THIS LINE) _________________________________________________________________ This document is hereby approved and filed in the Office of the Commissioner of Insurance, Serial Number_________________ Agent’s License Number___________ ____________________________________ Commissioner of Insurance ____________________________________ DATE STATEMENT OF AGREEMENT TO SERVE AS INSURANCE AGENT Pursuant to Title 22, Section 753, of the Virgin Islands Code, I hereby agree to serve as agent for ___________________________________________________ of ____________________________________________in and for the Virgin Islands of the United States, and further agree that I will not rebate any part of the premium or commission or offer any valuable consideration as an inducement to take insurance other than that clearly expressed in the policy. Further, if I sign policies, I will maintain an office within the Virgin Islands and keep therein at all times a complete record of all applications for and policies of insurance placed by or through me, and will not sign any policies in blank to be issued outside my office. ____________________________________ ____________________________________ _______________________________________________________________________ Subscribed and sworn to be fore me this __________day of ____________________, 20___________at________________________________________________________ ____________________________________________ (Notary Public)