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Application for Certificate of Registration as Non-Life Company Underwriter
IC certificate application form for registration as non-life company
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 CERTIFICATE OF REGISTRATION AS
NON-LIFE COMPANY UNDERWRITER
FOR THE INSURANCE
COMMISSION USE
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: ____________________
Date:
_______________________
Processed by: _________________
Date:
_______________________
Approved by: __________________
Date:
_______________________
Registration Fee: P______________
O.R. No.: _____________________
Date: ________________________
Fire
Marine
Casualty
Suretyship
To the Insurance Commissioner:
The undersigned hereby applies for Certificate of Registration under the provisions of Chapter
(Insurance Company)
IV, Title 4 of the Insurance Code as Non-Life Company Underwriter of __________________________
_______________________________________________________________ in respect of the kinds
of insurance indicated herein:
FIRE
MARINE
CASUALTY
SURETYSHIP
and for that purpose submits the following statements and answers to the questions contained in this
applications.
1.
Name of applicant:_______________________________________________________________
(Surname)
(First Name)
(Middle Name)
2.
Present Address: ________________________________________________________________
3.
Place of Birth: __________________________________________________________________
4.
Date of Birth: ___________________________________________________________________
5.
Citizenship: _______________ Sex:___________
6.
If married woman, state (a) Maiden Name: __________________________________________
(b) Husband’s or Wife’s Name: ________________________________
7.
If naturalized citizen of the Philippines, give date of issue of naturalization and attach photostatic
copy of certificate of naturalization. __________________________________________________
______________________________________________________________________________
8.
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. ___________________
______________________________________________________________________________
9.
Have you ever been discharged from any position? _________________________ If yes, state
particulars. _____________________________________________________________________
Civil Status:
_______________________
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
work. _________________________________________________________________________
______________________________________________________________________________
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. _______________________________________________
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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
payment.
16. Give complete record of your education (Name and location of schools attended and length of time
spent in each.)
Elementary :
________________________________________________________________
High School :
________________________________________________________________
College :
________________________________________________________________
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.
Inclusive Dates
From – To
Name of Employer
Where
In What Capacity
Reason for
Leaving
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.
Name
Occupation
Post Office Address
1.
2.
3.
4.
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
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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
TIN: _________________________
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 _____.
Notary Public
Doc. No.
Page No.
Book No.
Series of 20
______
______
______
______
IC-LLI-DP-005-F-01
Rev.0
4
