APPOINTMENT OF AGENT
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, V.I. 00820 TEL-340-774-7166 FAX-340-774-5590 TEL-340-773-6459 FAX-340-719-3801 APPOINTMENT OF SOLICITOR Pursuant to Title 22, Section 762, of the Virgin Islands Code, the undersigned Producer hereby applies for authorization for ________________________________________________________________________ (Name of Solicitor) ________________________________________________________________________ (Business Address of Solicitor) ________________________________________________________________________ (Kind[s] of insurance solicitor will write) The above Solicitor is hereby authorized to solicit and accept applications on behalf of the following Producer within the U.S. Virgin Islands effective _________________. …
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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, V.I. 00820 TEL-340-774-7166 FAX-340-774-5590 TEL-340-773-6459 FAX-340-719-3801 APPOINTMENT OF SOLICITOR Pursuant to Title 22, Section 762, of the Virgin Islands Code, the undersigned Producer hereby applies for authorization for ________________________________________________________________________ (Name of Solicitor) ________________________________________________________________________ (Business Address of Solicitor) ________________________________________________________________________ (Kind[s] of insurance solicitor will write) The above Solicitor is hereby authorized to solicit and accept applications on behalf of the following Producer within the U.S. Virgin Islands effective _________________. (Date) ______________________________________________________________________________ (Name of Insurance Producer) _______________________________________ __________________________________ Authorized Signatory of Producer to appoint/terminate Signature (DO NOT WRITE BELOW THIS LINE) This document is hereby approved and filed in the Office of the Commissioner of Insurance: Solicitor’s license number ____________________. _______________________________________ _____________________________ Commissioner of Insurance Date STATEMENT OF AGREEMENT TO SERVE AS INSURANCE SOLICITOR Pursuant to Title 22, Section 762, of the Virgin Islands Code, I hereby agree to serve as an insurance solicitor for ____________________________________________ (Name of License Producer) of ___________________________________ in and for the Virgin Islands of the United (City) (State) States. I understand that, pursuant to Title 22, Section 762, I do not have the power to cover any kind of insurance for which the producer by whom I am employed is not then licensed. Further, I do not have the power to bind an insurer upon or with reference to any risk or insurance contract, or to countersign insurance contracts. _________________________________ Solicitor’s Signature Subscribed and sworn to before me this ____ day of _______________, 20_____ at _________________________________. (City) (State) _________________________________ Notary Public