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Application for Registration as Resident Agent of an Unauthorized Foreign Insurer or Broker
IC application form for registration as resident agent of an authorized foreign insurer or broker
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Finance
INSURANCE COMMISSION
Manila
APPLICATION FOR REGISTRATION AS RESIDENT AGENT
OF AN UNAUTHORIZED FOREIGN INSURER OR BROKER
(To be accomplished by the applicant who must be a citizen
and resident of the Philippines)
The Insurance Commissioner:
Manila
Sir/Madam:
The undersigned resident agent of ________________________________________________
__________________________________________________________________________________
hereby applies for registration, pursuant to the provisions of Chapter IV, Title 3 of the Insurance Code,
as amended (RA 10607) and for that purpose submits the following statements and answers to the
questions contained in this application:
1.
Name of applicant:_______________________________________________________________
2.
a) Date of Birth: _______________________ b) Place of Birth: __________________________
c) Sex: _______ d) Civil Status:__________________ e) Citizenship: _____________________
3.
Business Address: ______________________________________________________________
4.
Residence Address: _____________________________________________________________
(If applicant is a naturalized citizen of the Philippines, attach photostatic copy of certificate of
naturalization.)
5.
Is the applicant duly authorized to receive notices, summons and legal processes for and in behalf
of the foreign insurer or broker he represents in connection with the action or other legal
proceedings in the Philippines against such foreign insurer or broker? _________ If yes, attach
copy of the power of attorney duly notarized and authenticated by the Philippine consul in the
place where such foreign insurer or broker is domiciled.
6.
Is the applicant duly covered by insurance against all liability that may arise in connection with the
performance with the performance of his duties as such resident agent? _____________ If yes,
attach copy of the policy of insurance to that effect.
7.
What experience and/or training has the applicant in the insurance business? _______________
State in what branches or kinds of insurance, in what capacity, and where and when engaged.
______________________________________________________________________________
8.
State the amount of fee received as resident agent. _____________________________________
9.
Submit copy of certificate of authority or license or registration certificate of the principal duly
certified to by the insurance supervisory or its equivalent where said principal is authorized to do
insurance business.
10. Submit copy each of the audited financial statement of principal for the least three (3) years.
11. State below the names and addresses of four (4) responsible persons for reference.
Name
Occupation
Post Office Address
1.
2.
3.
4.
Executed this _____ day of _________________20 _____, at __________________________
______________________, Philippines.
_____________________________________
Applicant
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AFFIDAVIT OF VERIFICATION
Republic of the Philippines)
Province/City of _________) S.S.
I, ___________________, 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.
_____________________________
Applicant - Affiant
TIN
_________________
SUBSCRIBED AND SWORN TO before me this _______ day of ______________________
20 _____, applicant - affiant exhibited to me his/her Community Tax Certificate No. _______________
issued on __________________, __________________________________________20 _______, at
___________________________________________.
Notary Public
Doc. No.
Page No.
Book No.
Series of 20
______
______
______
______
IC-LLI-DP-005-F-03
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(Insurance Company)
APPROVED AND COUNTERSIGNED for _________________________________________
___________________________________________ to act as insurance/general agent of the
insurance company in the negotiation, solicitation or sale of authorized life/non-life or other line of
insurance products/policies in accordance with the agency agreement, Insurance Commission’s
circulars and Insurance Code. We promise to inform the Insurance Commission in case of the
termination of the services of the agent or the agency agreement.
____________________________________
Authorized Representative of the Company
Note:
This form may be revised without prior notice.
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