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Application for Renewal of Adjusters License

IC renewal application form for adjusters license

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Department of Finance
INSURANCE COMMISSION
Manila

APPLICATION FOR RENEWAL OF CERTIFICATE OF REGISTRATION
AS RESIDENT AGENT

___________________________
Date

The Insurance Commissioner
Manila
Sir/Madam:
The undersigned hereby applies for the renewal of the Certificate of Registration to as Resident
Agent of __________________________________________________________________________
for the year beginning 01 January 20 ____, under Chapter IV, Title 3, Section 322 of the Insurance
Code as amended (RA 10607).
Attached are the following requirements in support of this application:
1.
2.
3.

4.
5.

Original Certificate of Registration
Audited Financial Statement of principal for the preceding year or if principal is a broker, the
list of company/ies where such broker had placed Philippine business
Copy of renewed Certificate of Authority or License or Registration Certificate of the principal,
duly certified to by the insurance supervisory authority or its equivalent where said principal is
authorized to do insurance business
Documentary Stamp
Copy of the current Errors and Omissions Policy of the principal foreign insurance broker

__________________________________
Application (Company/Corporation)

By: __________________________________
Authorized Company/Corp. Official

IC-LLI-DP-OO8-F-02
Rev.0
 
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