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Application for Renewal of License as Insurance Agent

IC renewal application form for insurance agent license

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Department of Finance
INSURANCE COMMISSION
Manila
APPLICATION FOR RENEWAL OF LICENSE AS INSURANCE AGENT

___________________________
Date
The Insurance Commissioner
Manila
Sir/Madam:
The undersigned hereby applies for the renewal of the licenses attached hereto, to
do business in the Philippines for the year beginning 01 January 20 ____, under Chapter IV,
Title 1, Section 307 of the Insurance Code as amended (RA 10607) of the insurance agents
of _______________________________________________________________________
listed in the attached form:
We hereby certify:
1.

That on the basis of the withholding tax for (BIR Form) 1743.1) of said agents we
found the amount of commission or other compensation for services rendered as
insurance agents for the preceding year is not less that P 3,600.00 each.

2.

That the said agents, if they are company or corporation or agency, have submitted
audited financial statements;

3.

That the said agents have paid the corresponding Privilege Tax

4.

That the said agents have submitted copy of their Income Tax Return;

5.

That the said agents, if they are aliens, have submitted aliens’ annual fee for the
current year;

6.

That the said agents, if they are partnership or corporation, have complied with the
Value Added Tax System;

7.

That copies of the documents pertaining to the statements in the preceding subparagraphs 1 to 6 are on file with our company;

8.

That the personal information of the said agents appears in Schedule A.

AND WE HEREBY AGREE that should the foregoing be found to be false in any
respect, the licenses so renewed shall be immediately cancelled without prior notice and the
persons responsible therefore shall be dealt with in accordance with law.
Attached is ______________________ Check No. ___________________________
in the amount of ____________________________________________________________
(P _______________) for ____________________________________ ( ) ordinary agents
and _______________________________________________ ( ) general agents licenses
and _______________________________________ ( ) pieces of documentary stamps at
P ____________ each.

Very truly yours,

________________________________________
President or Senior/Exec. Vice Pres.
________________________________________
________________________________________
(Insurance Company)

SUBSCRIBED AND SWORN TO before me this ____ day of __________________,
20____, affiant having exhibited his/her Community Tax Certificate No. _________________
issued on ____________________________, 20____ at ___________________________.

Notary Public

Doc. No.
Page No.
Book No.
Series of 20

______
______
______
______

IC-LLI-DP-OO7-F-01

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