Philippine Government Forms All in One Location
Application for Certificate of Registration as Non-Life Company Underwriter
IC certificate application form for registration as non-life company
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Department of Finance
APPLICATION FOR CERTIFICATE OF REGISTRATION AS
NON-LIFE COMPANY UNDERWRITER
FOR THE INSURANCE
INSTRUCTIONS TO APPLICANTS
Read these instructions before accomplishing this
form. This application will not be accepted unless all
information called for are furnished.
Accomplish this form legibly and fully. Sign the
application on the space indicated.
This application must be accompanied with a
documentary stamp which shall affixed to the certificate of
registration applied for.
Verified by: ____________________
Processed by: _________________
Approved by: __________________
Registration Fee: P______________
O.R. No.: _____________________
To the Insurance Commissioner:
The undersigned hereby applies for Certificate of Registration under the provisions of Chapter
IV, Title 4 of the Insurance Code as Non-Life Company Underwriter of __________________________
_______________________________________________________________ in respect of the kinds
of insurance indicated herein:
and for that purpose submits the following statements and answers to the questions contained in this
Name of applicant:_______________________________________________________________
Present Address: ________________________________________________________________
Place of Birth: __________________________________________________________________
Date of Birth: ___________________________________________________________________
Citizenship: _______________ Sex:___________
If married woman, state (a) Maiden Name: __________________________________________
(b) Husband’s or Wife’s Name: ________________________________
If naturalized citizen of the Philippines, give date of issue of naturalization and attach photostatic
copy of certificate of naturalization. __________________________________________________
If foreigner, give serial number, date and place of issue of alien certificate of registration for the
current year and attach photostatic copy of alien certificate of registration. ___________________
Have you ever been discharged from any position? _________________________ If yes, state
10. Have you ever been convicted of any crime? __________________ If yes, give nature of offense
and attach copy of the decision of the court concerned. __________________________________
11. Have you passed any qualifying examination for non-life company underwriter given by the
Insurance Commissioner? ______________ If yes, give date and place of examination, rating
obtained and proof to that effect. ___________________________________________________
12. Have you had any experience in underwriting work? ________ If yes, state for how long, where, in
what branches or kinds of insurance, and submit proofs and/or results of your entire underwriting
b) Have you received or undergone extensive education and/or training in each of the kind or
kinds of insurance you propose to register under the certificate herein applied for? ____________
If yes, give the name of the person from whom you have received education and/or instructions,
specify the kinds of insurance in which you have been instructed, and attach satisfactory proof/s to
that effect. _____________________________________________________________________
13. Are you a licensed insurance agent? ___________ If yes, state the names of the insurance
companies you represent. _________________________________________________________
14. Are you indebted to any person (natural of juridical)? __________ If yes, give the names and
addresses of your creditors together with details and evidences of the arrangements you have
made for the settlement of your debts. _______________________________________________
15. Have you filed your income tax return for the preceding year? _________ If not, give reason.
___________________________________________ If yes, attach proof of such filing and/or
16. Give complete record of your education (Name and location of schools attended and length of time
spent in each.)
High School :
Technical Course/Special Course :
17. In the blanks below, state how you have been occupied during the last ten (10) years (without
interruption) up to date of this application, irrespective of whether employed or not. Attach
additional sheet/s, if necessary.
From – To
Name of Employer
In What Capacity
18. Give below the names, occupation and addresses of four (4) responsible persons for reference.
Do not give the name of a relative or a former employer or one connected with the company
wherein you wish to be employed.
Post Office Address
19. Are you a member of any association, club or society? ______________ If yes, state name,
address and nature of organization. _________________________________________________
20. Name of bank with which you are keeping an account, if any. _____________________________
21. Name of person to be notified in case of emergency, relationship and address: _______________
Executed this ___________ day of _________________________________, 20_____ at
Signature of Applicant
AFFIDAVIT OF VERIFICATION
Republic of the Philippines )
Province/City of _________) S.S.
I, ___________________, after being duly sworn, depose and say that I am the person named
in and who signed the foregoing application; that I know that the contents thereof and the statements
made and answers to questions therein are true.
Signature of Applicant
SUBSCRIBED AND SWORN TO before me this _______ day of ______________________
20___, by the above-named applicant who exhibited to me his/her Residence Certificate No.
_________________________________________ issued at ______________________________ on
_______________________________ 20 _____.
Series of 20