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 COMPANY REGISTRATION FORM NONRESIDENT INDEPENDENT ADJUSTER 1. Company Name: __________________________________________ E.I.N. ___________________________ 2. Physical Address in state of Domicile: Street ___________________________________ Apt/Suite # ________ City _____________________________ State _________________ Zip Code ________________ Telephone number ( ) - _______ - ___________ Fax number ( ) - _______ - __________ b) MAILING: Street/P.O. Box _________________________________Office/Suite# _________ City _________________________________ State ________________ Zip Code __________ 3. …
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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 COMPANY REGISTRATION FORM NONRESIDENT INDEPENDENT ADJUSTER 1. Company Name: __________________________________________ E.I.N. ___________________________ 2. Physical Address in state of Domicile: Street ___________________________________ Apt/Suite # ________ City _____________________________ State _________________ Zip Code ________________ Telephone number ( ) - _______ - ___________ Fax number ( ) - _______ - __________ b) MAILING: Street/P.O. Box _________________________________Office/Suite# _________ City _________________________________ State ________________ Zip Code __________ 3. Physical Address while residing in the Virgin Islands: License Number ____________ Street ___________________________________ Apt/Suite # ________ City _____________________________ State _________________ Zip Code ________________ Telephone number ( ) - _______ - ___________ Fax number ( ) - _______ - __________ b) MAILING: Street/P.O. Box _________________________________Office/Suite# _________ City _________________________________ State ________________ Zip Code __________ 4. Name of Person’s working on behalf of Company while in the Virgin Islands: Name:___________________________ Telephone Number _________________ Name:___________________________ Telephone Number _________________ BY SIGNATURE HERETO I hereby certify that the information provided in this application is true and correct. Date:__________ Company's Name:_______________________ By:___________________________________ Title:_________________________________ Subscribed and Sworn to before me this ______ day of _________________, 20___. ________________________________ Notary Public Commission Expires:_______________ Commission Number:_______________ NOTE: Please attach a copy of the Company's adjusting license from state of domicile along with a list of all adjusters working under the company's license.