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Application for Adjuster License
IC application form for adjuster license
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 ADJUSTER’S LICENSE
(Under Chapter IV, Title 5 of the Insurance Code)
INSTRUCTIONS TO APPLICANTS
FOR THE INSURANCE
COMMISSION USE
Verified by: ____________________
Accomplish this form legibly and fully in your own
handwriting. This application will not be accepted unless all
information called for are furnished.
Date:
_______________________
If applicant is a partnership, association or
corporation, questions 3, 4, 5, 6 9, 10(b), 11, 12, 14, 15, 16
and 17 refers to the officer of the partnership, association or
corporation authorized to accomplish this application and
whose name appears under No. 8 hereof.
Date:
If applicant is a partnership, association or
corporation organized or existing under any law other than
those of the Philippines or more than thirty (30%) percent of
the outstanding capital of which is owned or controlled by
aliens, the said applicant must also submit copies of the
certificate from the Board of Investments pursuant to R.A.
No. 5453 authorizing it to transact or engage in any
economic activity in the Philippines.
License Fee: P ________________
O.R. No.: _____________________
Date: ________________________
Processed by: _________________
_______________________
Approved by: __________________
Date:
_______________________
License No. ______________
Independent
Adjuster
If the officer of the partnership, association or
corporation making this application is a foreigner, he/she
must present to the Insurance Commission his/her Alien
Certificate of Registration for the current year.
Should the license applied for be issued, the holder
thereof must notify the Insurance Commissioner of facts
stated in this application which have been changed, such as
address, change of directors and/or officers, etc.
The applicant or the individual mentioned in Item No.
8 must submit with this application, two (2) identical
passport size copies of his/her recent photograph and a
documentary stamp to be affixed to the license to be issued.
Public
Adjuster
Fire
Marine
Casualty
To the Insurance Commissioner:
The undersigned hereby applies for a license to act as Independent/Public Adjuster of
Fire/Marine/Casualty insurance claims and for that purpose submits the following statements and
answers to the questions contained in this application:
____________________________________________________
Business Name
1.
Full Name of Applicant: ___________________________________________________________
2.
Present Address: ________________________________________________________________
3.
Date of Birth: ______________________ Place of Birth: _______________________________
4.
Citizenship: ______________________ Civil Status: __________________________________
5.
If naturalized citizen of the Philippines, give date and place of naturalization. _________________
______________________________________________________________________________
6.
If foreigner, give serial number, date and place of issue of Alien Certification of Registration for the
current year. ___________________________________________________________________
______________________________________________________________________________
7.
(a) If applicant is a partnership, association or corporation, state whether same is registered in the
Securities and Exchange Commission or in the Bureau of Commerce and in the affirmative case,
attach hereto a copy each of the Articles of Incorporation, Association or Incorporation, as the
case may be, of the partnership, association or corporation and its By-Laws.
(b) If applicant is a partnership, association or corporation, state what percentage of its capital
belongs to citizens of the Philippines. ___________________________ (Attach a list showing the
names, address and nationalities of the partners, members or stockholders, as the case may be
as well as the amount of participation or stocks owned by each as of the date of this application.)
8.
If applicant is a corporation, attach list showing (a) the names, addresses and dates of election of
the members of its Board of Directors and of its officers; and (b) the names, addresses, and date
of employment of the members of its staff authorized to adjust on fire, marine, average and/or
casualty losses for the company, as well as their respective educational attainments and previous
experiences.
9.
Have you ever been discharge from any position?__________ If yes, state particulars _________
______________________________________________________________________________
10. (a) Has any person listed under No. 8 been accused of any crime? ________ (If yes, attach copy
of decision of the Court).
(b) Have you ever been accused of any crime? _______ (If yes, attach copy of decision of the
Court.)
11. What experience or training have you had as an adjuster in the line of insurance claims adjustment
for which a license is now being applied? (You may indicate your answer on a separate sheet of
paper which should be attached hereto.) _____________________________________________
______________________________________________________________________________
2
12. Are you indebted to any person (natural or juridical)? __________ If yes, give names and
addresses of creditors and also details and evidence of the arrangements you have made for the
settlement of your debts. __________________________________________________________
______________________________________________________________________________
13. Have you filed your income tax returns for the preceding year? _________ If no, state reason.
______________________________________________________________________________
14. 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 :
______________________________________________
15. If applicant has successfully completed an academic or training program in the kind of insurance
contemplated in the license applied for, attach hereto proof to that effect.
16. In the following 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.
Inclusive Dates
From – To
Name of Employer
Where
In What Capacity
Reason for
Leaving
17. 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 anybody connected with the company
which you wish to represent.)
Name
Occupation
Post Office Address
1.
2.
3.
4.
18. Are you a member of any association, club or society? ______________ If so, give name,
address and nature of organization. _________________________________________________
______________________________________________________________________________
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___, affiant who 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-003-F-01
Rev.0
4
