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OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION 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 ORIGINAL INSURANCE APPLICATION FOR RESIDENTS OR NON-RESIDENTS (INDIVIDUAL) 1. LICENSE TYPE: Check box that applies for each category. Applicant must complete a separate application for each license type. a)  Resident  Non-Resident ** if assigned, National Producer Number (NPN) ____________________ b)  Producer  Independent-Adjuster  Public-Adjuster  Surplus Line Broker  Managing General Agent Solicitor c)  Life  Accident, Health or Sickness  Property  Casualty  Title  Variable Life and Variable Annuity  Surety Personal Lines  Credit  Travel Insurance  Rental Car  Self Storage  Communications Equipment or Services d)  Are you a veteran?  YES  NO e)  Are you a US Citizen?  YES  NO 2. NAME O F APPLICANT: ❑ Mr. ❑ Mrs. ❑ Ms. Last First Middle Name: 3. IDENTIFICATION INFORMATION: S.S.N. Sex: M F Date of Birth: Place of Birth: MM/DD/YYYY City, State Personal Email Address _____________________________________________________________________________ 4. BUSINESS ADDRESS: (P.O. Box not acceptable) Street ____________________________________________ Apt/Suite # _____________________________ City _________________________________ State _______________________ Zip Code ________________ Business Phone No: ( ) - ________ - _____________ Fax Phone No: ( ) - ______ - _______________ Email: Website: 5. RESIDENCE ADDRESS: (P.O. Box not acceptable) Street ____________________________________________ Apt/Suite # _____________________________ City _________________________________ State _______________________ Zip Code ________________ Home Phone No: ( ) - _________ - _________________ 6. MAILING ADDRESS:  Business  Residence Street/P.O. Box _____________________________________ Apt/Suite # ___________________________ City _________________________________ State _______________________ Zip Code _______________ 7. List any other assumed, fictitious, alias, or trade names which you have used in the past or under which you are currently doing business or intend to do business: Yes No (Copy of Tradename Certificate required for Residents only) If yes, please list name(s) ____________________________________________________________________________ 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 8. Are you now or have you ever used any name other than shown in (2) or (7)? Yes No If yes, list names, dates, and reasons used. Name Date Reason 9. PRODUCER LIFE AGENT APPLICANTS ONLY:  N/A a) If you intend to act as a Variable Life and Variable Annuity Agent, are you registered with the Division of Banking, Insurance and Financial Regulation? Yes No (If yes, provide your BD-A registration number. If no, state the reason why you have not registered.) b) If you intend to act as a Variable Life and Variable Annuity Agent, are you registered with NASD? Yes No Provide your Central Registration Depository (CRD) Number ________________________ 10. MANAGING GENERAL AGENT APPLICANTS  N/A List the names of the authorized companies which you will represent and from which you have received an appointment. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) 11. PRODUCERS APPLICANTS:  N/A a) If acting as an agent, list names of the authorized companies licensed in the Virgin Islands through which you will represent and from which you have received an appointment. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) b) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated _______________________________________________________________________________________ 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 12. 12. PRODUCERS APPLICATIONS:  N/A If acting as a resident broker, if available, list names of authorized companies through which business will be placed. (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) a) Name of the Agency on the U.S. Mainland or the U.S. Virgin Islands through which you are affiliated. _________________________________________________________________________________________ b) Residents only- Broker Bond Number __________________Expiration Date ______________ Amount $10,000 Surety Company ___________________________________________ ** Submission of original bond required 13. SOLICITOR APPLICANTS:  N/A Provide the name of the Agent and/or Agency with which you are appointed. (Submission of appointment required) 14. SURPLUS LINE BROKER APPLICANTS ONLY:  N/A a) List the names of all “unauthorized insurers” or “surplus lines carries” that are eligible to conduct surplus lines business in the Virgin Islands with which arrangements have been made to accept or which are considering the acceptance of surplus lines business offered by applicant: (You must list the full and exact legal name of each company. Abbreviated names or the names of parent companies are not acceptable.) Eligible Unauthorized Insurers in the Virgin Islands b) Residents only- Broker Bond Number ___________________Expiration Date ______________ Amount $10,000 Surety Company _______________________________________ ** Submission of original bond required 15. RESIDENT ADJUSTER APPLICANTS ONLY:  N/A If you are an Office Manager, list names of adjusters working directly under your supervision: 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 16. ADJUSTER APPLICANTS:  N/A List Companies with which you are affiliated: 17. PUBLIC ADJUSTER APPLICANTS:  N/A Broker Bond Number _______________________Expiration Date _________________ Amount $10,000 Surety Company _______________________________________ **Submission of original bond required 18. AGENCY OR BUSINESS ENTITY AFFILIATIONS: List your Insurance Agency Affiliations: (Complete only if applicant is to be licensed as an active member of the business entity): FEIN ________________________ NPN _____________________ Name of Agency____________________________ FEIN ________________________ NPN _____________________ Name of Agency____________________________ FEIN ________________________ NPN _____________________ Name of Agency____________________________ 19. ALL APPLICANTS: If you hold or have ever held an insurance license, complete the following:  N/A Type of License State Resident Nonresident Date License Held Lines of Authority From To 20. ALL APPLICANTS: List your places of residents for the past five years. From (MM/YYYY) To (MM/ YYYY) Street City State Postal Code 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 21. ALL APPLICANTS: List your occupation (employment) for the past five years to current: From (MM/YYYY) To (MM/YYYY) Employer Name Address Duties Performed BACKGROUND QUESTIONS 1 a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a misdemeanor? Yes ___ No___ You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence (DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license. You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court) 1 b. Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony? Yes ___ No___ You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court) If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of insurance in your home state as required by 18 USC 1033? Yes ___ No___ If so, was consent granted? (Attach copy of 1033 consent approved by home state.) 1 c. Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with committing a military offense? Yes ___ No___ NOTE: For Questions 1a, 1b and 1c, “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine. If you answer yes to any of these questions, you must attach to this application: a) a written statement explaining the circumstances of each incident, b) a copy of the charging document, c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment. 2. Have you ever been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding regarding any professional or occupational license or registration? Yes ___ No___ “Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a prohibition order, a compliance order, placed on probation, sanctioned or surrendering a 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 license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If you answer yes, you must attach to this application: a) a written statement identifying the type of license and explaining the circumstances of each incident, b) a copy of the Notice of Hearing or other document that states the charges and allegations, and c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment. 3. Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others. Yes ___ No___ If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and location of bankruptcy. 4. Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement? Yes ___ No___ If you answer yes, identify the jurisdiction(s): _______________________________________ 5. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? Yes ___ No___ If you answer yes, you must attach to this application: a) a written statement summarizing the details of each incident, b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings, and c) a copy of the official documents, which demonstrates the resolution of the charges or any final judgment. 6. Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any alleged misconduct? Yes ___ No___ If you answer yes, you must attach to this application: a) a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you from receiving an insurance license, and b) copies of all relevant documents. 7. Do you have a child support obligation in arrearage? Yes ___ No___ If you answer yes, a) by how many months are you in arrearage? b) are you currently subject to and in compliance with any repayment agreement? c) are you the subject of a child support related subpoena/warrant? (If you answered yes, provide documentation showing proof of current payments or an approved repayment plan from the appropriate state child support agency.) 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 8. In response to a “yes” answer to one or more of the Background Questions for this application, are you submitting document(s) to the NAIC/NIPR Attachments Warehouse? Yes ___ No___ If you answer yes Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application? Yes ___ No___ Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this application, you must go to the Attachments Warehouse and associate (link) the supporting document(s) to this application based upon the particular background question number you have answered yes to on this application. You will receive information in a follow-up page at the end of the application process, providing a link to the Attachment Warehouse instructions. Applicant’s Certification and Attestation The Applicant must read the following very carefully: 1. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may subject me to civil or criminal penalties. 2. Unless provided otherwise by law or regulation of the jurisdiction, I hereby designate the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction is of the same legal force and validity as personal service upon myself. 3. I further certify that I grant permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company. 4. I further certify that, under penalty of perjury, a) I have no child-support obligation, b) I have a child-support obligation and I am currently in compliance with that obligation, or c) I have identified my child support obligation arrearage on this application. 5. I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information. 6. I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure. 7. For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested from the non-resident state. 8. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or requested by the jurisdiction(s). __________________________________________________ Month/Day/Year __________________________________________________ Original Applicant Signature 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 The following items are needed for licensure: Identification (Gov’t issued, i.e.: Driver’s license, Passport, Voter’s Registration Card, etc. ------------------ Tax Clearance Letter ----------------------------------------- Producer’s Bond ------------------------------------------------- Surplus Lines’ Bond -------------------------------------------- Public Adjuster’s Bond ---------------------------------------- Managing General Agent Three Letters of Recommendation---------------------------- Written Examination------------------------------------------- Original License Fee-------------------------------------------- Appointment Forms & Fee------------------------------------- Resident only Resident only Resident only Resident only Resident and Non-Resident Resident and Non-Resident Resident only Resident and Non-Reciprocal Licensees Resident & Non-Resident Resident & Non-resident RESIDENT ORIGINAL FEE BOND Solicitor $400.00 N/A Producer $400.00 $10,000.00 (if acting as a broker) Appointment Fee- (if acting as an agent) $ 50.00 N/A Managing General Agent $850.00 if applicable Surplus Line Broker $500.00 $10,000.00 Adjuster (Independent/Public) $500.00 $5,000.00 (Public Only) NON-RESIDENT ORIGINAL FEE BOND Producer $700.00 N/A Surplus Line Broker $500.00 N/A Managing General Agent $850.00 if applicable Adjuster (independent/Public) $500.00 $5,000.00 (Public Only) Appointment Fee (if acting as an agent) $ 50.00 N/A All checks and money orders must be made payable to Government of the U.S. Virgin Islands. FOR OFFICE USE ONLY Receipt Number: _______________________ Date: __________________ Amount: $_________________ (REV: 05/2017)