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Application for Insurance Broker's License
IC license application form for insurance 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 INSURANCE BROKER’S LICENSE
(Under Chapter IV, Title 1 of the Insurance Code)
FOR THE INSURANCE
COMMISSION USE
INSTRUCTIONS TO APPLICANTS
Accomplish this form legibly and fully in your own
handwriting. This application will not be accepted unless
all information called for are furnished.
This application must be accompanied with a
documentary stamp which shall be affixed to the license
being applied for.
Every applicant shall also file with the application
a bond in such amount as may be determined by the
Insurance Commissioner, but in no case less than Five
Hundred Thousand Pesos ( P 500,000.00) and two (2)
Errors and Omissions Insurance Policy (Professional
Liability or Professional Indemnity Policy) as required
under IMC No. 2-85 dated 7 August 1985.
Verified by: ____________________
Date:
_______________________
Processed by: _________________
Date:
_______________________
Approved by: __________________
Date:
_______________________
License Fee: P ________________
O.R. No.: _____________________
Date: ________________________
To the Insurance Commissioner:
The undersigned hereby applies for a license as insurance broker, pursuant to the provisions of
Chapter IV of the Insurance Code, and in support of this application represents as follows:
1.
Name of applicant:_______________________________________________________________
(If applicant is a partnership, association or corporation, Items 2 to 9 apply to the individual or
person duly authorized to act for and in its behalf and whose name shall be stated in the license to
be issued.)
2.
(a)
Date of Birth: ____________________
(b)
Place of Birth: _______________________
3.
(a)
Sex: ___________________________
(b)
Civil Status: ________________________
4.
Business Address: _________________________________________________________
(b)
Residence Address:
(a)
Citizenship: _______________________________________________________________
(b)
5.
(a)
If a naturalized citizen of the Philippines, give date and place of naturalization and attach
photostatic copy of certificate of naturalization. ___________________________________
_________________________________________________________________________
_______________________________________________________
6.
Have you ever been dishonorably discharged from any position of employment? ______________
If yes, state particulars. ___________________________________________________________
7.
Have you ever been accused of any crime? __________________ If yes, attach copy of court’s
decision.
8.
Have you filed your income tax return for the preceding year? _________ If yes, attach proof of
such filing, otherwise, give reason for not filing.
9.
What experience and/or training have you had in the insurance business? State in what branches
or kinds of insurance, in what capacity, and where and when engaged. _____________________
______________________________________________________________________________
10. If applicant is a partnership, association or corporation:
(a)
Attach certified true copy each of the Certificate of Registration, Articles of Partnership,
Association or Incorporation and By-Laws; and
(b)
State percentage of Filipino participation in the partnership, association or corporation as of
the date of this application. ________________________________________
11. Is the applicant (and the individual duly authorized to act in its behalf, if applicant is a partnership,
association or corporation) duly covered by an Errors and Omissions Policy or Professional
Liability or Professional Indemnity Policy? ___________ If yes, attach copy of the policy.
12. If the applicant is an alien individual or domestic enterprise which is a non-Philippine national, or
more than 40% of the outstanding capital of which is owned or controlled by non-Philippine
nationals, attach written authority from the Board of Investments, under Republic Act No. 5455, as
amended by Executive Order No. 226 (The Omnibus Investments Code of 1987) to do business or
engage in an economic activity in the Philippines.
13. Have you ever been licensed by this Office to act as insurance broker or agent? _________ If yes,
please state the full circumstances. _________________________________________________
______________________________________________________________________________
14. Are you an official stockholder or employee or an insurance company? ___________ If yes, state
the name of the company and percentage of ownership, if any. ____________________________
______________________________________________________________________________
15. Are you a licensed insurance agent? _____________ If yes, state the name/s of the insurance
company/ies you represent. _______________________________________________________
______________________________________________________________________________
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16. In the blanks below, state how you have been occupied during the last ten years (without
interruption) up to the date of this application, irrespective of whether employed or not. (Attach
additional sheet, if necessary).
Inclusive Dates
From – To
Name of Employer
In what
Capacity
Where
Under Whom
Reason for
Leaving
17. State below the names and addresses of four (4) responsible persons for reference.
Name
Occupation
Post Office Address
Executed this ___________ day of _________________________________, 20_____ at
____________________________________________.
__________________________________
Signature of Applicant
TIN :
3
____________________________
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.
_____________________________
Signature of Applicant
SUBSCRIBED AND SWORN TO before me this _______ day of ______________________
20___, by the above-named applicant who exhibited to me his/her Community Certificate Tax No.
___________________________________ issued ______________________________, 20 _____
at _____________________________________.
Notary Public
Doc. No.
Page No.
Book No.
Series of 20
______
______
______
______
IC-LLI-DP-003-F-02
Rev.0
4
