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Application for Renewal of Insurance Brokers License

IC renewal application form for brokers license

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Department of Finance
INSURANCE COMMISSION
Manila
APPLICATION FOR RENEWAL OF INSURANCE BROKER’S LICENSE

___________________________
Date
The Insurance Commissioner
Manila
Sir/Madam:
The undersigned hereby applies for the renewal of license to do business in the Philippines as
insurance broker for the year beginning 01 January 20 ____, under Chapter IV, Title 1, Section 307 of
the Insurance Code as amended (RA 10607) and in support thereof, represents as follows:
1.

Name of applicant: ______________________________________________________________

2.

Address: ______________________________________________________________________
______________________________________________________________________
Tel. No.: ______________________________________________________________________

3. Percentage of foreign participation: __________________________________________________
Attached are the following pertinent documents necessary for the renewal of said license:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Original License
Renewed Errors and Omission Policies
Renewed Surety Bond
Verified photocopy of ITR of company
Verified photocopy of ITR of soliciting official/s
Audited Financial Statement of company
Value Added Tax (VAT) receipts
Documentary Stamp
Updated List of Officers, Board of Directors and Stockholders (Compliance with Circular
Letter 2-97)

__________________________________
Applicant (Company/Corporation)
By: _______________________________
Authorized Company/Corp. Official

IC-LLI-DP-OO6-F-03
Rev.0
 
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