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Application for License as a Mutual Benefit Association
IC license application form for mutual benefit association
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 CONTROLLED INSURER
The Insurance Commissioner
Manila
Sir/Madam:
The undersigned, the ________________________________________________
hereby applies for registration as a controlled insurer under the provisions of Section 286
of the Insurance Code and submits the following facts:
1.
The applicant is authorized to transact the business of _______________________
insurance in the Philippines under Certificate of Authority No. _________________
issued on _________________________.
2.
The applicant is controlled directly or indirectly by __________________________
____________________ hereinafter referred to as the “Holding Company,” with
principal office at ____________________________________________________.
3.
Attached is a copy of the Articles of Incorporation and By-Laws of the Holding
Company.
4.
The names and addresses of the Holding Company’s principal shareholders, officers
directors and controlled persons are as follows: (Use additional sheet, if necessary.)
A.
Principal Shareholders
Name
B.
Address
Officers
Name
Address
C.
Directors
Name
D.
Address
Controlled Persons
Name
Address
5.
The Holding Company’s capital structure and financial condition as of the preceding
calendar year are as follows: (Use additional sheet, if necessary.)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6.
The principal business activity/ies of the Holding Company are as follows:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Executed this _______________ day of ____________________, 200_____ at
____________________________.
______________________________
(Name of Corporation)
By: __________________________
(President)
By: __________________________
(Secretary)
2
AFFIDAVIT OF VERIFICATION
Republic of the Philippines)
Province/City of _______)S.S.
______________________________ and ______________________________
being duly sworn and severally sworn, each for himself deposes and states that the said
______________________________
is
the
President
and
the
said
______________________________
is
the
Secretary
of
the
__________________________________________________; that he/she signed the
foregoing application by order of the Board of Directors; and that he has read said
application and knows the contents thereof and that the statements therein contained
are true to the best of his knowledge.
______________________________ ______________________________
Affiant
Affiant
SUBSCRIBED AND SWORN TO before me this ___________ day of
__________________, 200_____. Affiants exhibited their respective Community Tax
Certificates as follows: No. ____________________ issued at ____________________
on _________________________, and No. ____________________ issued at
____________________ on _________________________, respectively.
______________________________
NOTARY PUBLIC
Doc. No.
__________
Page No.
__________
Book No.
__________
Series of 200__________
3
