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REQUIREMENTS FOR INITIAL CERTIFICATE OF AUTHORITY Date ______________________ Account No. _________________________ Name of Insurer ____________________________________________________________ Type of Insurance ____________________________________________________________ New Application Package for Review and Approval The following documents and filing fees must be submitted: □ $300.00 □1. Non-Refundable Processing Fee □ $ 25.00 □2. Application for Admission □ $150.00 □3. Certified Copy of Charter of Certificate of Incorporation/Articles of Incorporation and Amendments □$ 25.00 □4. Certified Copy of By-Laws and Amendments □$ 25.00 □5. Certificate of Compliance from Insurance Department of S State or Country of domicile □$ 25.00(ea) □6. Biographical Affidavits ( =$ ) □$ 25.00 □7. Management Information Form □ No Fee □8. Company Contact List □$ 25.00 □9. Examination Report □$ 25.00 □10. Management Discussion and Analysis Forms □$ 25.00 □11. Business Plan □$ 25.00 □12. Statement of the Company’s Financial Condition, Management and Affairs (Most recent quarterly statement acceptable) □$ 20.00(ea) □13. Applicable Policy Forms and Rate Manuals ( =$ ) □$ 25.00 □14. Appointment of Commissioner of Insurance as Agent for Service of Process Form and A Resolution adopted by the Board of Directors of the Company Authorizing Appointment of Commissioner as Agent for Service of Process, pursuant to Section 218, Title 22 of the Virgin Islands Code, consenting that: Service of process upon the Commissioner in any action or proceeding against the company, brought or pending in the Virgin Islands upon any cause of action arising in or growing out of business transacted in the Virgin Islands, shall be valid service upon the company, and the consent shall be irrevocable, so long as a policy of insurance of such company shall remain in force in the Virgin Islands or any loss remains unpaid therein. □$ 50.00(ea) □15. Appointment of Producer/Statement of Agreement to serve as Insurance Producer Forms □$ 25.00 □16. Appointment of Agent for Service of Process/Consent of Agent for Service of Process Forms □ No Fee □17. Executed Surety Bond or Certificate of Deposit Agreement evidencing statutory deposit in the following amounts and executed through a Company licensed in the Virgin Islands (must be submitted before license is issued): TITLE INSURERS $100,000.00 ALL OTHER INSURERS $500,000.00 I. PRELIMINARY EXAMINATION Pursuant to Title 22 of the Virgin Islands Code, Section 206(3): An insurer shall submit to a personal examination of its affairs by the Commissioner. The examination shall include a background of the business dealings of the insurer, the insurer’s organizers, principals, Board of Directors and corporate officers. The Commissioner may waive the examination if there is filed with him a certified copy of an examination made within one year immediately preceding the insurer’s application for a license to do business in the Virgin Islands by a state insurance department or other insurance certification authority. II. CAPITAL AND SURPLUS REQUIREMENTS Pursuant to Title 22 of the Virgin Islands Code, Section 451: Minimum Minimum Capital Surplus Required Initially Required 1. Life insurance $1,000,000 $500,000 2. Disability insurance: 1,000,000 250,000 (A) Life and disability insurance 1,250,000 750,000 3. Property insurance 2,000,000 950,000 4. Marine and transportation insurance 2,500,000 1,250,000 5. Casualty insurances: (A) Vehicle only 2,000,000 1,000,000 (B) General casualty 3,000,000 1,500,000 6. Surety insurance: (A) Surety 1,000,000 4,000,000 (B) Bail bonds only 500,000 250,000 7. Title insurance: In accordance with the provisions of Chapter 47 of Title 22 8. All Insurance, except life and title insurances 4,500,000 2,500,000 III. ADDITIONAL FEES □$1,100.00 □ Initial Certificate of Authority Fee (Fee must be submitted upon approval before license is issued) APPLICATION FOR ADMISSION BY AN INSURANCE COMPANY DOMESTIC/FOREIGN/ALIEN TO THE COMMISSIONER OF THE VIRGIN ISLANDS: The ____________________________________________________________ (NAME OF COMPANY) incorporated on _____________________________________ in: (1) ______________________________________________________________ (2) ______________________________________________________________ One of the United States of America or Territory of the U.S. other than the Virgin Islands, District of Columbia or Puerto Rico (3) ______________________________________________________________ -Nation outside of the United States for the purpose of transacting _____________________________________________________ ______________________________________________________________________________ with a capital of $___________________________, and a surplus of $_____________________ hereby applies for admission to the Virgin Islands on ______________________________ with renewal from year to year, subject to the approval of the Commissioner and to such changes in fees as the legislature may prescribe to be payable, and to the strict observation of all laws or amendments thereto, which may be prescribed by statute for the regulation of the insurance business in the Virgin Islands, and in conformity with the charter and by-laws of said company and the rules of procedure provided by the Insurance Department. The President, Secretary, and Treasurer herein represent that the company has fully complied with the provisions of its charter and by-laws, in that state of incorporation, that the company is in sound financial condition and that its method of underwriting and conducting business are known and permitted by the insurance officials of the state where incorporated and approved by the directors of the company. ________________________ President Dated: _____________________________ ________________________ Secretary Every license expires on December 31st of each calendar year ________________________ OFFICE OF THE COMMISSIONER DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION UNITED STATES VIRGIN ISLANDS _________________MANAGEMENT INFORMATION FORM_______________ COMPANY NAME:______________________________________________ Names and Titles of the Officers: Name Titles: (Officers) Names and Titles of the Directors: Name Titles: (Directors) BIOGRAPICAL AFFIDAVIT (Print or Type) Full Name and Address of Company (Do Not Use Group Names.) ______________________________________________________________________________ In connection with the above-named company, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) IF ANSWER IS "NO" OR ''NONE'', SO STATE. 1. Affiant'sFull Name (Initials Not Acceptable) _______________________________ _________________________________________________________________________ 2. a. Have you ever had your name changed? _______________________________ If yes, give the reason for the change. _______________________________ b. Other names used at any time. _____________________________________ 3. Affiant's Social Security Number. ___________________________________________ 4. Date and Place of Birth. _________________________________________________ 5. Affiant's Business Address. _________________________________________________ Business Telephone. _______ - ________ - ___________ 6. List your residences for the last ten (10) years starting with your current address, giving: DATE ADDRESS CITY AND STATE _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 7. Please provide details of your education: College/School Name: DATE DEGREE LOCATION College: ______________________________________________________________ ______________________________________________________________ Graduate: ______________________________________________________________ ______________________________________________________________ Other: ______________________________________________________________ ______________________________________________________________ 8. List Membership in Professional Societies and Associations. ________________________ _________________________________________________________________________ _________________________________________________________________________ 9. Present or Proposed Position with the Applicant Company. _________________________ _________________________________________________________________________ 10. List complete employment record (up to and including present jobs, positions, directorates or officerships) for the past twenty (20) years, giving: DATES EMPLOYER AND ADDRESS TITLE __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 11. Present employer may be contacted. YES □ NO □ Former employers may be contacted. YES □ NO □ 12. (a) Have you ever been in a position, which required a fidelity bond? ______________ If any claims were made on the bond, give details __________________________ ____________________________________________________________________ (b) Have you ever been denied an individual or position schedule fidelity bond, or had a bond cancelled or revoked? __________ If yes, give details. ________ ____________________________________________________________________ ____________________________________________________________________ 13. List any professional, occupational, and vocational licenses issued by any public or governmental licensing agency or regulatory authority, which you presently hold or have held in the past (place and date, license issued, issuer of license, date terminated, reasons for termination). __________________________________________________________ ________________________________________________________________________ 14. During the last ten (10) years, have you ever been refused a professional, occupational, or vocational license by any public or governmental licensing agency or regulatory authority, or has any such license held by you ever been suspended or revoked?________ If yes, give details. ________________________________________________________ ________________________________________________________________________ 15. List any insurers in which you control directly or indirectly or own legally or beneficially 10% or more of the outstanding stock (in voting power). __________________________ ________________________________________________________________________ If any of the stock is pledged or hypothecated in any way, give details._______________ ________________________________________________________________________ 16. Will you or members of your immediate family subscribe to or own, beneficially or of record, shares of stock of the applicant insurance company or its affiliates? ________ If any of the shares of stock are pledged or hypothecated in any way, give details.______ ________________________________________________________________________ 17. Have you ever filed bankruptcy? If yes give details ______________________________ 18. a. Have you ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or been pardoned for conviction of or pleaded guilty or nolo contendere to an information or indictment charging any felony, or charging a misdemeanor involving embezzlement, theft, larceny, or mail fraud, or charging a violation of any corporate securities statute or any insurance law, or have proceedings of any federal or state regulatory agency? ______________________ If yes, give details. ________________________________________________ ___________________________________________________________________ b. Has any company been so charged, allegedly as a result of any action or conduct on your part? ___________________ If yes, give details. _______________________ ___________________________________________________________________ 19. Have you ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any insurer which, while you occupied any such position or capacity with respect to it, became insolvent or was under supervision or in receivership, rehabilitation, liquidation or conservatorship? ______________________ If yes, give details. _____________________________________________________ 20. Has the certificate of authority or license to do business of any insurance company of which you were an officer or director or key management person ever been suspended or revoked while you occupied such position? ________________________ (See Rider A) If yes, give details. ______________________________________________________ ________________________________________________________________________ Dated and signed this the ______day of _____________, 20___ at ______________________ I hereby certify under penalty of perjury that I am acting on my own behalf and that the foregoing statements are true and correct to the best of my knowledge and belief. ____________________________________ (Signature of Affiant) State of _________________________ County of _________________________ Personally appeared before me the above named ____________________________________ Personally known to me, who, being dully sworn, deposes and says that s/he executed the above instrument and that the statements and answers contained therein are true and correct to the best of her/ his knowledge and belief. Subscribed and sworn to before me this the ______ day of ___________________, 20____. ____________________________________ (Notary Public) (Seal) My commission expires __________ Government of the United States Virgin Islands Office of the Commissioner-Division of Banking, Insurance and Financial Regulation #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 TEL: 340-774-7166 FAX: 340-774-5590 COMPANY CONTACT LIST CONTACT PERSON(S) FOR:_________________________________________ (Please indicate Company’s full legal name) 1. Company’s President: ________________________________________________ (Print name) Business Address: ___________________________________________________ Mailing Address: ____________________________________________________ Telephone No._____________________________ Fax No.___________________ Statutory Home Office Address _________________________________________ _________________________________________ Telephone No._____________________________ Fax No.___________________ Main Administrative Office Address _____________________________________ _____________________________________ Telephone No._____________________________ Fax No.___________________ 2. Contact Person for Premium Tax Quarterly Filings Name/Title: _________________________________________________________ Mailing Address: ____________________________________________________ ______________________________________________________ Telephone No. ___________________________Fax No._____________________ E-Mail _____________________________________________________________ 3. Contact Person for Annual Statement and Audited Financial Report Filing Name/Title: _________________________________________________________ Mailing Address: ____________________________________________________ _____________________________________________________ Telephone No.________________________ Fax No.________________________ E-Mail_____________________________________________________________ 4. Contact Person for Licensure and related filings Name/Title: __________________________________________________________ Mailing Address: ______________________________________________________ ______________________________________________________ Telephone No. ________________________Fax No.__________________________ E-Mail_______________________________________________________________ 5. Contact Person for Policy Forms Name/Title: __________________________________________________________ Mailing Address: ______________________________________________________ _______________________________________________________ Telephone No. ________________________ Fax No.________________________ E-Mail______________________________________________________________ 6. Contact Person for Consumer Complaints Name/Title: __________________________________________________________ Mailing Address: ______________________________________________________ _______________________________________________________ Telephone No. __________________________Fax No._______________________ E-Mail:______________________________________________________________ 7. Contact Person – Company’s Statutory Deposit Name/Title: __________________________________________________________ Mailing Address:______________________________________________________ _______________________________________________________ Telephone No. ___________________________Fax No.______________________ E-Mail______________________________________________________________ 8. Authorized Signatory to Appoint and Terminate Agents in the U.S. Virgin Islands Print Name Signature ________________________________ ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ 9. List Name of Agent(s)/Agency currently representing Company in the U.S. Virgin Islands for marketing of products: ________________________________ _________________________________ ________________________________ _________________________________ 10. General Agent resident in the U.S. Virgin Islands to appoint subagents: ________________________________ _________________________________ ________________________________ _________________________________ 11. 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 FORM: Name________________________________________ Date______________________ (Please Print) Signature _______________________________________________________________ Relationship to Company___________________________________________________ E-Mail:_____________________________ Telephone No.________________________ APPOINTMENT OF COMMISSIONER OF INSURANCE AS AGENT FOR SERVICE OF PROCESS ~ײ~ KNOW ALL MEN BY THESE PRESENTS That the ____________________________________________________________________________ a foreign corporation, incorporated and organized under the laws of the State of____________________ ______________________________________, now authorized or having applied for authority to do an insurance business in the Virgin Islands, hereby appoints the Commissioner of Insurance of said Virgin Islands and his successors in office, its true and lawfully ATTORNEY, in and for the Virgin Islands, upon whom all lawful process against said insurer may be served in any action or proceeding in the Virgin Islands, subject to and in accordance with all provisions of the Insurance Laws of said Virgin Islands in force at the time of such service, which shall not be terminated so long as there are in effect any contracts, or liabilities or duties arising out of contracts, which were issued or delivered by such insurer in the said Virgin Islands. IN WITNESS WHEREOF, The said________________________ ___________________________________ in accordance with the resolution of its Board of Directors duly passed on the _____ day of ________________, 20 ____, a copy of which is filed herewith, has to these presents affixed its corporate seal, and caused the same to be subscribed and attested by its President and Secretary, at the city of________________________________ in the State of __________________________________________ on the ___________ day of ____________________, 20 ________ ______________________________________________________ By _____________________________________, President ATTEST: _________________________________, Secretary STATE OF ________________________________ County of ____________________, To Wit: I, _______________________________________, a Notary Public in and for the County and State aforesaid, do certify that _____________________________ personally appeared before me in my said county, and being by me duly sworn, did depose and say, that they are respectively the President and the Secretary of the Corporation described in writing above, bearing date the ____________ day of ______________________, 20__________, authorized by said corporation to execute and acknowledge deeds and other writings of said Corporation, and that the seal affixed to said writing is the Corporate seal of said Corporation and that said writing was signed by them in behalf of said Corporation by its authority duly given. And the said _________________________ acknowledged the said writing to be the act and deed of said Corporation. Given under my hand and official seal this ____ day of ______________, 20 ____ ____________________________________ Notary Public Notary Seal: APPOINTMENT OF AGENT FOR SERVICE OF PROCESS IN ACCORDANCE WITH SECTION 218 (B) OF TITLE 22 ~ײ~ KNOW ALL MEN BY THESE PRESENTS That the _______________________________________________________________ a foreign corporation, incorporated and organized under the laws of the State of______ __________________________________________now authorized or having applied for authority to do insurance business in the Virgin Islands of the United States, hereby appoints_________________________________ of ____________________________ (Name of Agent) (City) its true and lawful Attorney in and for the Virgin Islands upon whom all lawful process against said insurer may be served in an action or proceeding in the Virgin Islands, subject to and in accordance with all the provisions of the Insurance Laws of the Virgin Islands in force at the time of such service, which appointment shall remain in full force and effect until such time as the agent’s authority shall have been revoked by a notice in writing duly served upon the agent and filed in the Office of the Insurance Commissioner of the Virgin Islands. IN WITNESS WHEREOF, The said _____________ _______________________ pursuant to authority (Company) given by ___________________________________ __________________________________________ has to these presents affixed its corporate seal, and caused the same to be subscribed and attested by its________________________________________ (give titles of authorized officers) at the City of _______________________ in the State of _____________________ on the _____day of ______________________________, 20 _____ __________________________________________ (Company) __________________________________________ (Signature and Titles of Officers) ATTEST: _______________________________________ (Signature and Title of Officer) CONSENT OF AGENT FOR SERVICE OF PROCESS ~ײ~ This writing witnesseth that the undersigned of _________________________________ (City) Virgin Islands of the United States, having been designated by the _________________ (Name of Company) ______________________________________________________________________ as agent of the said company upon whom services in the Courts of the Virgin Islands, do hereby consent to act as such agent, and that service of process may be made upon me in accordance with Title 22 of the Virgin Islands Code. IN WITNESS WHEREOF, I have hereunto set my signature this ________day of ______________________ 20_________. ___________________________________ (Print Agent’s Name) __________________________________________ (Signature of Agent) ___________________________________________ (Agent’s Physical Address) ___________________________________________ ___________________________________________ (Agent’s Contact Number) Subscribed and sworn to before me this ______________day of ____________, 20_______ at ___________________________. __________________________________ (Notary Public) Government of the United States Virgin Islands Office of the Commissioner-Division of Banking, Insurance and Financial Regulation #5049 Kongens Gade, Charlotte Amalie, St. Thomas, V.I. 00802 1131 King Street, Suite 101, Christiansted, VI 00820 TEL: 340-774-7166 FAX: 340-774-5590 TEL: 340-773-6459 FAX: 340-719-3801 Appointment of Producer Pursuant to Title 22, Section 753, of the Virgin Islands code, the undersigned insurance company hereby applies for authorization for: _________________________________________________________________ (Name of Producer) ________________________________________________________________ (Business Address of Producer / Post Office Box not accepted) _________________________________________________________________ (Kinds of Insurance Producer will write) The above producer 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 ___________ 20___. ________________________________________________________________________ (Please print full legal name of Insurance Company) __________________________________________________________________________ (To be signed by an authorized signatory designated to appoint and/or terminate producers in the United States Virgin Islands) ________________________________________________________________________ (Print Name) _________________________________________________________________ (DO NOT WRITE BELOW THIS LINE) This document is hereby approved and filed in the Office of the Commissioner of Insurance, ____________________________________ ___________________ Commissioner of Insurance Date STATEMENT OF AGREEMENT TO SERVE AS INSURANCE PRODUCER Pursuant to Title 22, Section 753, of the Virgin Islands Code, I hereby agree to serve as producer ______________________________________________________ of (Please print full legal name of Insurance Company) _________________________________________ in and for the Virgin Islands of the (Company’s State of Domicile) 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, I shall keep at my address as shown on my license, during all business hours a complete record of all transactions to include applications for and policies of insurance placed by or through me pursuant to Title 22, Section 784, of the Virgin Islands Code, and will not sign any policies in blank to be issued outside my office. _______________________________________ Signature of Producer Authorized Signatory _______________________________________________________________________ Subscribed and sworn to before me this __________day of ____________________, 20___________at________________________________________________________ ____________________________________________ (Notary Public) DEPOSITORY AGREEMENT THIS AGREEMENT made in triplicate between the Lieutenant Governor of the Virgin Islands as the Commissioner of Insurance (the "Commissioner") and the ____________________________ (the “Bank) and the ________________________________ (the “Depositor” or “Insurance Company”). WHEREAS Section 207(a) of Title 22 Virgin Islands Code provides that all foreign and alien insurers shall file with the Commissioner of Insurance as a condition of doing business in the U.S. Virgin Islands, and for the protection of policyholders in the U.S. Virgin Islands, the sum of not less than Five Hundred Thousand Dollars ($500,000), which may be in the form of a financial guarantee bond, certificate of deposit, letter of credit or U.S. Treasury Notes; and WHEREAS the Depositor, an insurance company, organized under the laws of __________________ has applied for a certificate of authority to transact the business of insurance upon risks in the U.S. Virgin Islands. NOW THEREFORE, the parties agree as follows: 1. The Depositor has deposited with the Bank the securities listed and described on Exhibit "A" attached hereto and made a part of this Agreement, which Exhibit shall be amended and kept current during the term hereof so as to record all changes in the list of securities deposited pursuant to this Agreement. The purpose of such deposit is to protect the Depositor's policyholders in the U.S. Virgin Islands, and the deposit shall be held in trust for that purpose and in the manner and under the conditions described in paragraph 2 hereof to satisfy all judgments, decrees, or orders given, made or rendered against the Depositor by any court of the U.S. Virgin Islands for the payment of money. 2. The Bank hereby acknowledges and certifies that it has received from the Depositor for deposit with and safekeeping by the Bank, the securities listed and described on Exhibit "A". The Bank upon written order of the Commissioner, where a judgment or decree has been given, made or rendered against the Depositor by the Court of the U.S. Virgin Islands for payment of money and said judgment, decree or order has become final, and a period of thirty (30) days has elapsed shall turn over to the Commissioner such securities as he shall designate for the purpose of paying to the successful party in the action, suit or proceeding the amount of said judgment, decree or order. Notwithstanding anything contained herein, the Bank shall be obligated to turn over the securities upon the written order of the Commissioner and that the Bank shall in no event be liable to any party hereto, or to any other party whenever it shall act in accordance with any such written order. 3. Withdrawal, substitution or exchange of the securities deposited pursuant to this Agreement may be made only upon the prior order or approval of the Commissioner. 4. The Depositor agrees that it will keep on deposit with the Bank at all times securities of a fair market value of at least $500,000. Depository Agreement 5. Any interest or dividends accruing to any securities deposited in accordance with this Agreement shall accrue to that account of the Depositor. If the securities deposited hereunder carry interest coupons, such coupons shall be delivered directly to the Depositor by the Bank in accordance with whatever agreement is entered into by them. 6. The Depositor shall bear all costs, including any fees charged by the Bank incident to this agreement, and the Government of the U.S. Virgin Islands, its officers, agents and employees, including the Commissioner, shall in no way be liable for any such costs or fees; provided, however, that this agreement may be terminated by the bank upon thirty (30) days notice to the Commissioner and Depositor if all such costs and fees are not paid. 7. It is specifically understood and agreed that the Commissioner is authorized to sell the whole or part of the securities deposited hereunder or any substitutes therefor or additions thereto at any broker's board or at public or private sale, at his option, without advertisement or notice to the Depositor and to use the proceeds thereof for the purposes of effectuating the objectives of this Agreement. 8. The term of this Agreement shall commence on the effective date of the initial Certificate of Authority issued to the Insurance Company, and shall continue in force and effect until the conditions for release or withdrawal of the securities deposited or filed have been satisfied or met in accordance with Sections 207(c) and 709 of Title 22 Virgin Islands Code. IN WITNESS WHEREOF the parties have executed this Agreement on the dates indicated opposite their names. Dated: __________________ Government of the U.S. Virgin Islands Witnesses: By: _________________________________________ Lieutenant Governor ___________________________ Commissioner of insurance ___________________________ Before me, the undersigned Notary, personally appeared ___________________ on this _____ day of ____________, 20____ known to me to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same for the purpose therein contained. IN WITNESS WHEREOF I have hereunto affixed my hand and official seal. ____________________________ Notary Public Depository Agreement Dated: ________________ _____________________________ Bank Witnesses: By: __________________________ _____________________________ Title: _________________________ _____________________________ STATE OF __________________________) COUNTY OF ________________________) ss: Before me, the undersigned Notary, personally appeared __________________ on this ____ day of ________, 20___ who acknowledged himself/herself to be the _____________________ of _______________________, a corporation, and that he/she as such _______________________ being authorized so to do, executed the within instruments for the purposes therein contained by signing the name of the corporation by himself/herself as _______________________. IN WITNESS WHEREOF I have hereunto affixed my hand and official seal. __________________________________ Notary Public Dated: ______________ _________________________________________________________ Insurance Company Witnesses: By: ____________________________________ _______________________________ Title: _________________________ ______________________________ STATE OF _____________________________) COUNTY OF _____________________________) ss: Before me, the undersigned Notary, personally appeared___________________ on this ____ day of ________, 20___ who acknowledged himself/herself to be the _____________________ of _______________________, a corporation, and that he/she as such _______________________ being authorized so to do, executed the within instruments for the purposes therein contained by signing the name of the corporation by himself/herself as _______________________. IN WITNESS WHEREOF I have hereunto affixed my hand and official seal. ___________________________ Notary Public Depository Agreement Deposit Agreement “Exhibit A” The following security is to be placed on the deposit per the DEPOSITORY AGREEMENT for _____________________________________________________ (Company Name) Cusip/Acct. No. _______________________________________________________________ Description _______________________________________________________________ Interest Rate _______________________________________________________________ Maturity Date _______________________________________________________________ Par Value _______________________________________________________________ SURETY BOND KNOW ALL MEN BY THESE PRESENTS, That the undersigned………………...… ………………………………….……………………………………………as principal, of …………………………………...…. and the undersigned……………………………………. ………………………………………………, as surety, are held and firmly bound unto the Commissioner of Insurance, Government of the Virgin Islands of the United States, and his successors in office, as oblige, in the full and just sum of …………………………………… to which payment we bind ourselves and our respective successors and assigns jointly and severally by these presents. WHEREAS, the laws of the Government of the Virgin Islands of the United States (Section 207, Title 22 of the Virgin Islands Code) require all foreign insurance companies to file with the Insurance Commissioner of the Virgin Islands, if he deems it advisable for the protection of policyholders in the Virgin Islands, a good and sufficient surety bond in a sum not less than Five Hundred Thousand ($500,000.00) Dollars. AND WHEREAS, the ………………………………………………….. aforesaid, desires to transact business within the Territory of the Virgin Islands of the United States and has been informed by the Commissioner of Insurance, Government of the Virgin Islands of the United States, that he requires a bond in the amount of…………………………… …………………………………………… and does by this instrument furnish and file said bond. NOW, THEREFORE, the condition of the above bond is such that if the principal shall answer to the amount of the bond for all judgments, decrees or orders given, made or rendered against the principal by any court of the Virgin Islands of the United States for the payment of money, then this bond to be void and of no effect; otherwise, to remain in full force and effect. PROVIDED, HOWEVER, that the surety shall have the right to terminate its suretyship under this obligation by serving written notice of its election to do so upon the Commissioner of Insurance of the Government of the Virgin Islands of the United States, not less than ninety (90) days prior to the date on which the then existing certificate of authority of the principal is to expire. Surety shall, however, remain liable hereunder for all judgments, decrees or orders given, made or rendered against the principal, based on obligations incurred during the period of suretyship. IN WITNESS WHEREOF, the said principal and said surety have set their hands and affixed their seals this…………………….. day of ………………….20……… Principal: _______________________________ Attest: ______________________________ Secretary By ____________________________ (Officer) -2- STATE OF ) SS: COUNTY OF ) On this the …………………….. day of………………………………, 20……… before me the undersigned Notary personally appeared…………………………………… who acknowledged himself to be the ………………………………………………………. of …………………………………………………..……, a corporation and that he, as such …………………………………………..., being so authorized to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as ………………………………….. In Witness Whereof I hereunto set my hand and official seal. _______________________________________ (Notary Public) Surety ………………………………………… ATTEST: ____________________________________ Secretary By …………………………………………….. (Officer) STATE OF ) SS : COUNTY OF ) On this the ………………….day of ……………………………, 20……., before me the undersigned Notary personally appeared………………………………………………. who acknowledged himself to be the ………………………………………………………. of ……………………………………………………….., a corporation and that he, as such …………………………………………., being so authorized to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as …………………………………………. In Witness Whereof I hereunto set my hand and official seal. ______________________________________ (Notary Public) SURETY BOND (Title Company Only) KNOW ALL MEN BY THESE PRESENTS, That the undersigned………………...… ………………………………….……………………………………………as principal, of …………………………………...…. and the undersigned……………………………………. ………………………………………………, as surety, are held and firmly bound unto the Commissioner of Insurance, Government of the Virgin Islands of the United States, and his successors in office, as oblige, in the full and just sum of …………………………………… to which payment we bind ourselves and our respective successors and assigns jointly and severally by these presents. WHEREAS, the laws of the Government of the Virgin Islands of the United States (Section 1152, Title 22 of the Virgin Islands Code) require title insurer to file with the Insurance Commissioner of the Virgin Islands, if he deems it advisable for the protection of policyholders in the Virgin Islands, a good and sufficient surety bond in a sum not less than One Hundred Thousand ($100,000.00) Dollars. AND WHEREAS, the ………………………………………………….. aforesaid, desires to transact business within the Territory of the Virgin Islands of the United States and has been informed by the Commissioner of Insurance, Government of the Virgin Islands of the United States, that he requires a bond in the amount of…………………………… …………………………………………… and does by this instrument furnish and file said bond. NOW, THEREFORE, the condition of the above bond is such that if the principal shall answer to the amount of the bond for all judgments, decrees or orders given, made or rendered against the principal by any court of the Virgin Islands of the United States for the payment of money, then this bond to be void and of no effect; otherwise, to remain in full force and effect. PROVIDED, HOWEVER, that the surety shall have the right to terminate its suretyship under this obligation by serving written notice of its election to do so upon the Commissioner of Insurance of the Government of the Virgin Islands of the United States, not less than ninety (90) days prior to the date on which the then existing certificate of authority of the principal is to expire. Surety shall, however, remain liable hereunder for all judgments, decrees or orders given, made or rendered against the principal, based on obligations incurred during the period of suretyship. IN WITNESS WHEREOF, the said principal and said surety have set their hands and affixed their seals this…………………….. day of ………………….20……… Principal: _______________________________ Attest: ______________________________ Secretary By ____________________________ (Officer) - 2- STATE OF ) SS: COUNTY OF ) On this the …………………….. day of………………………………, 20……… before me the undersigned Notary personally appeared…………………………………… who acknowledged himself to be the ………………………………………………………. of …………………………………………………..……, a corporation and that he, as such …………………………………………..., being so authorized to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as ………………………………….. In Witness Whereof I hereunto set my hand and official seal. _______________________________________ (Notary Public) Surety ………………………………………… ATTEST: ____________________________________ Secretary By …………………………………………….. (Officer) STATE OF ) SS : COUNTY OF ) On this the ………………….day of ……………………………, 20……., before me the undersigned Notary personally appeared………………………………………………. who acknowledged himself to be the ………………………………………………………. of ……………………………………………………….., a corporation and that he, as such …………………………………………., being so authorized to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as …………………………………………. In Witness Whereof I hereunto set my hand and official seal. _______________________________________ (Notary Public)