1 APPLICATION PACKAGE FOR INTERMEDIARY INSURANCE LICENSING (AGENT, BROKER AND SOLICITOR) INSURANCE BOARD/COMMISSION FEDERATED STATES OF MICRONESIA TownPlaza building, Suite 12 P.O. Box K-2980 Kolonia Pohnpei, FM Phone: (691) /5426 Fax: (691) Website: fsminsuranceboard.com
2 This application package comprises of : PARTS A: Operational Document, PART B: Biographical Affidavit, and PART C: Checklist. Instruction Guideline Parts A, B and C of this application must be completed at entirety and thoroughly by all intermediary applicants as agent, broker and solicitor in order to engage in the insurance business in the Federated States of Micronesia (FSM). Applicants are required to label all supporting documents respective of the Part of the application and question therein for which such supporting documents are intended. Furthermore, all supporting documents should be filed concurrently with the application package. It is incumbent upon the applicant to ensure all statutory and regulatory application requirements per Section 302 of the FSM Insurance Act of 2006, as amended, are fully complied with when apply for a license. Additionally, an applicant has an ongoing duty to provide to the Insurance Board new or amended information relevant to its application while the application is pending and if a license is issued, after the issuance of the license. Do not leave any question unanswered. If a question does not apply, write NOT APPLICABLE. If you are not able to submit any of the documents requested, provide a detail explanation as to the reason(s). If a space for answer is insufficient, use additional sheet and label the additional sheet respective of the Part of the application and question for which the additional sheet is intended. Note: Section 303 of the Insurance Act stipulates that The Insurance Board shall review a completed application and conduct any further investigations ad deemed necessary, including public hearings, and approve or reject the application at the discretion of the Insurance Board including consideration of the following factors... Applicants are advised of the following key Subsections in Section 301 of the FSM Insurance Act of 2006, as amended: (a) Subsection 4 stipulates that only agents transacting insurance business on behalf of licensed or registered insurers shall be eligible for license, (b) Subsection 6 stipulates that a foreign insurer who does not make the premium collections (USD $2 million dollars) described in Subsection 5 of Section 301 shall be permitted to do business through a person licensed as an agent if the foreign insurer is registered, unless such foreign insurer chooses to be licensed as an insurer instead, and (c) Subsection 7 requires that a person licensed as an agent may conduct business on behalf of more than one insurer; however, the agent must apply for a separate license as an insurance agent for each insurer. An applicant is expected to get familiar with all relevant provisions in the FSM Insurance Act of 2006, as amended. An applicant should read, comprehend and comply fully with the applicable requirements of the Insurance Act of 2006 and, if the applicant is licensed comply fully with all the relevant provisions of the Act. A copy of the application package is available in Microsoft Word, if needed. Feel free to contact us if you need further assistance or clarifications on the application. Incomplete application will not be accepted.
3 PART A: OPERATIONAL DOCUMENT 1. Type of license applying for : Broker s License Agent s License Solicitor s License 2. Legal status of the business intermediary: Corporation Partnership Sole Proprietorship Other: If the applicant is a corporation, provide the following: (a) Corporate charter, (b) Certificate of incorporation, and (c) Bylaws and/or Articles of Incorporation. If the applicant is other than a corporation, documentation on the applicant s legal nexus, status or establishment in the Federated States of Micronesia is required, i.e. business license. 3. Full name and address of the applicant: address: 4. Full name and contact information on the authorized individual to be contacted in connection with the application: address: 5. Is the applicant currently engaging in insurance business or any other business? No Yes. If yes, provide brief description of the business, a copy of the current license and past three years audited financial statements or reports, or other documents attesting to financial responsibility. 6. Principal name and address in the FSM where the applicant will transact insurance business and maintain records (if different than #3 above): address: 7. If the applicant is to depend on a representative resident for service of process, provide full name and contact information on the appointed Representative Resident for service of process to whom notices and orders under the FSM Insurance Act of 2006 shall be sent. Provide also documentation on such designation or appointment:
4 address: 8. Classes and lines of insurance business to be transacted or solicited by the applicant: 9. Full name and address of the carrier or insurer. In the case of the applicant is a solicitor, the full name an address of the carrier or agent: 10. A written confirmation from the authorized officer of the applicant or applicant s carrier or (agent in the case the applicant is a solicitor applicant) that: (a). the applicant is a person of good character and reputation; (b). the applicant possess an educational background and experience that are appropriate to the responsibilities as an agent or solicitor of the sponsoring carrier; (c). the applicant be licensed to represent the carrier or insurer; (d). the sponsoring carrier or insurer has established and maintained a system to ensure that the applicant complies with statutory, regulatory and best practices as an intermediary; and (e). types or lines of insurance policies to be carried through the applicant in the FSM. 11. Provide copies of all executed agreements (i.e. agency agreement, etc). 12. If the applicant is a sole proprietorship, partnership or association, the Biographical Affidavit and curriculum vitae detailing insurance experience must be provided by the owner, partner or member. 13. If the applicant is a sole proprietorship, partnership, or association, provide full name and address of the owner, partner or all members thereof; if it is a corporation, the name and address of all officers. Each member or officer is also required to complete the Biographical Affidavit and detailed Curriculum Vitae. File these documents with the application. Name: Title: Full address: 14. Is the applicant a subsidiary? No Yes. If yes, provide the following on the parent company: (a) Approved constitutional documents.
5 (b) (c) (d) A confirmation signed by the authorized officer of the applicant s parent company in respect to its approval for the establishment of its subsidiary in the FSM to engage in insurance intermediary business and lines of insurance to be transacted. Past three years audited financial reports. Full name and address of each director and officer appointed by the parent company. Biographical affidavit on each is required, using PART B: Name: Address: If the applicant is an extension or branch, provide the following: a. Audited financial statements or reports for the last three years of operation. b. Original document issued by the applicant s home country licensing and supervisory authority stating that: i. the applicant is in compliance with all applicable laws and regulations of its home country, ii. the applicant is not currently subject to any supervisory enforcement actions or measures, iii. the home country licensing and supervisory authority has no objection for the applicant to be licensed in the FSM to engage in the type of insurance business proposed. iv. The home regulatory authority is prepared to cooperate on a regulator-to-regulator basis. c. Current financial strength rating assigned by a recognized international insurance rating agency satisfactory to the Insurance Commissioner, if applicable. d. Full name and address of the applicant representative resident in the Federated States of Micronesia. The applicant s representative resident or authorized representative is required to complete the Biographical Affidavit. e. Business plan. 16. Provide the certificate of professional indemnity insurance policy or Errors and Omissions policy covering fraud and negligence. 17. Are any of the parties named in this application currently involved or ever been involved with an insurance entity in any other jurisdiction, or has applied to any authority to transact insurance business in any jurisdiction? No Yes. If yes, provide details: 18. Provide a Business Plan detailing the business strategy, accounting system and reporting system. The business plan must include at least three years balance sheet, income and expense and cash flow projections with written assumptions used to formulate the projections. (Use a separate sheet of paper, if needed). 19. Provide detail information on the capital structure of the business, including the initial amount of capital, the source of capital funds, dividend policy, investment policy, loan back policy, etc.
6 20. The name, address and details of external or independent auditor for the proposed business. 21. Management staff, if any is to be employed by the applicant, must also provide their Biographical Affidavit and curriculum vitae detailing insurance experience. (The applicant is expected to vet the fitness and probity of such person(s). 22. Enclose in the application package the application and license fees. CERTIFICATION I acknowledge that the FSM Insurance Board may disclose information in the performance of its statutory functions or otherwise as may be specifically authorized by law. I hereby verify the foregoing answers and statements and declare that they were made under the penalties of perjury. I warrant that all other information was disclosed which might reasonably be considered relevant for the purpose of the application. At any time, if any of the above information changes, I will notify the FSM Insurance Board during the review of the application and, if the application is accepted, thereafter, within fifteen (15) days from the occurrence of the changes or recollection. I have read and completely understood the relevant and applicable provisions of the FSM Insurance Act of 2006, as amended, and will comply fully as set forth therein. I will act and hold myself out and carry on the business of insurance intermediary in good faith. Signed this day of, 20. (Authorized Signature of applicant) (Full name) (Title) Declared before me this day of, 20. (Seal) (Notary Public Signature) (Print or type full name) This application form could be provided in electronic form by contacting the below address or via an request. This application must be submitted in its original form with all the necessary documents and fees to: FSM Insurance Commissioner Insurance Board PO Box K-2980 Kolonia Pohnpei, F M Tel: (691) /5426 Fax: (691)
7 PART B: BIOGRAPHICAL AFFIDAVIT Instruction: This Form must be completed by: Owner in the case the applicant is a sole proprietorship. Partners in the case the applicant is a partnership. Members in the case the applicant is an association. Directors and officers in the case the applicant is a corporation. Management staff, if any, is to be employed by the applicant. Representative resident or authorized representative of the applicant. Insurance Solicitor (Name of Applicant) 1. Name of person completing this Biographical Affidavit: (First Name) (Middle Name) (Last Name) Title/Position: Previous name(s) or other names known by: Date of Birth (m/d/yr): Citizenship: Social Security No.: Provide a copy of your passport showing passport number, issuance and expiration dates, etc. 2. Residence for last ten years (include month and year): a). (From/To) (Street) (City) (State) (Zip) b). (From/To) (Street) (City) (State) (Zip) c). (From/To) (Street) (City) (State) (Zip) d). (From/To) (Street) (City) (State) (Zip) e). (From/To) (Street) (City) (State) (Zip) 3. Employment History: Provide the following information in reverse chronological order regarding your employment or selfemployment during the past ten (10) years. Use additional sheet(s) if necessary. Employer: From: To: Address: Phone: Fax: Website:
8 Business Description: Job Title and Description: Reason for Leaving: ******************************************************************************* Employer: From: To: Address: Phone: Fax: Website: Business Description: Job Title and Description: Reason for Leaving: 4. Educational and Professional Credentials (Use additional sheet if necessary): (a) Include high school (secondary) and postsecondary or college/university (indicate name of institutions, locations, dates attended, degrees, and major field of study): Postsecondary (graduate studies): Postsecondary (undergraduate): Secondary: (b) List any professional qualifications or license or similar certificates now held or have ever held, issuer, date issued, time currently being devoted to the profession and whether the license/certificate has been revoked, suspended or cancelled and the reasons, if applicable. (c) List training courses attended relevant to the position you are holding/will hold in the applicant. (Indicate title of training course, date, approximate period in terms of hours or days, weeks or years, and name and contact address of the institution provided the training.) 5. Provide original police clearance which should be dated within one (1) month prior to the signatory date of the application.
9 6. Has any insurance commissioner, regulatory authority or department ever suspended, cancelled, or revoked any license issued to you, or ever refused to issue or renew any such license, or have you ever surrendered any such license, or has any company cancelled any contract of employment or any appointment for any reason, or has any other public official or court ever suspended, cancelled or revoked any license or authority of any kind issued to you to pursue any trade, calling, or profession or refused to issue or renew any such license or authority or discharged or removed you from any public office or position? No Yes. If yes, provide details: 7. Have you ever filed a petition or have you been petitioned into bankruptcy or insolvency, or have you ever made any assignment for the benefit of, or any composition with your creditors, or have you ever been under guardianship or other legal disability? No Yes. If yes, provide details: 8. In your capacity as a natural person, sole owner of a business, employee, partner, member of an association, director, or officer, has there ever been a filed claim against you for being indebt to any individual, company, organization or institution (i.e. collected insurance premium, etc). No Yes. If yes, provide details: 9. Has there ever been a filed claim against you for being default on any repayment of debts (i.e. mortgage loan payments, credit payments, student loan payments, etc)? No Yes. If yes, provide details: 10. Are you a trustee, manager, director, officer or otherwise in charge, in whole or in part, of any property or interests of others who carry insurance? No Yes. If yes, provide details: 11. Have you ever been convicted of, or arrested or prosecuted for, any crime or offense against the laws or plead nolo contendere to any indictment or complaints for such crime or offense, or is there pending against you any indictment, complaint or proceeding for a violation of any laws, regulations, and/or orders? No Yes. If yes, provide details: 12. Listing of institutions in the FSM or outside of FSM you have been a significant shareholder, director or officer. Include percentage of ownership and description or position title. 13. Have you ever changed your name? No Yes. If yes, provide details: 14. Are you currently selling insurance over the Internet? No Yes. If yes, provide the name of your website and the location of server. 15. Have you or any corporation, partnership, or other entity in which, at the time you were an officer, director, trustee, sole owner, employee, partner and/or significant shareholder, been named in any complaint, pleading, judgment, order, or decree filed in any court of law which cited violations or alleged violations of any applicable laws? No Yes. If yes, provide details:
10 16. Have you ever been an officer, director, trustee, employee, partner, member, or significant shareholder of any financial institutions that became insolvent or were placed under supervision or in receivership, rehabilitation, liquidation or conservatorship while you occupied any such position or within one year thereafter? No Yes. If yes, provide details: 17. Has the certificate of incorporation or authority or license to do business which you were an officer, director, member, partner, member, or management staff ever been suspended, revoked or cancelled while you occupied any such position or within one year thereafter? No Yes. If yes, provide details: 18. Have you ever been requested, advised, ordered or told by any governmental regulatory authority, board, commission or agency to divest any stock ownership or other ownership interest you had in any company or organization? No Yes. If yes, provide details: 19. Have you ever been requested or asked to resign or leave as an officer, director, agent, employee, owner, member, partner, consultant or representative of any organization or institution? No Yes. If yes, provide details: 20. Have you ever been a named party in any legal or administrative hearing, proceeding or investigation in your capacity as a manager, staff, officer, director, trustee, employee, agent, owner, partner, consultant, advisor, authorized representative, or significant shareholder? No Yes. If yes, provide details. CERTIFICATION I hereby declare under penalty of perjury that the responses to the above are true and complete to the best of my knowledge and belief and there are no other facts or information relevant to this Biographical Affidavit which the FSM Insurance Board should be aware. I warrant that I will promptly notify the FSM Insurance Board of any changes in the information I have provided and supply any other relevant information, which may come to light in the period during which the application is being considered and, if the application is accepted, thereafter, within fifteen (15) days from the occurrence of the changes or recollection. I ALSO HEREBY AUTHORIZE the FSM Insurance Board to make such enquiries and seek such further information as appropriate to carry out its duties and responsibilities. Dated and signed this day of, 20 (Signature) (Print or type full name) Declared before me this day of, 20. (Seal) (Notary Public Signature) (Print or type full name)
11 PART C: CHECKLIST The Checklist is simply an aid to assist you in compiling a complete application prior to its filing. Depending on the legal status of the applicant, some of the documents may not be applicable. Make sure all the required supporting and relevant documents are filed with your application. It is incumbent upon the applicant to make sure all the supporting and relevant information or documents are provided at once with the application. In the case of a corporation: Corporate Charter Certificate of Incorporation Bylaws and/or Articles of Incorporation Biographical affidavits Copy of all agreements, even if they are in draft from Audited financial statements Business Plan Service of Process Agreement Etc. In the case a subsidiary: Parent company constitutional documents Confirmation (i.e. Board Resolution) signed by the parent company s authorized officer in respect to approval of the parent to establish the subsidiary in the FSM to engage in the business of insurance and lines of insurance to be transacted Past three years audited financial statements Copy of all agreements, even if they are in draft form Audited financial statements Business plan Service of Process Agreement Etc. In the case of Solicitor: Business license Agreement between applicant Solicitor and insurer or agent. Etc.
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JOHN A. GALE 1305 State Capitol Secretary of State Lincoln, NE 68509 DEBT MANAGEMENT LICENSE APPLICATION Initial Fee: $200.00 Investigation Fee: $200.00 Date of Application Applicant is a: Individual Partnership
1. Introduction MUTUAL FUND DEALERS ASSOCIATION OF CANADA INFORMATION REPORTING REQUIREMENTS (POLICY NO. 6) This Policy establishes minimum requirements concerning events that Approved Persons are required
05/10 Commonwealth of Puerto Rico COMMISSIONER OF FINANCIAL INSTITUTIONS Centro Europa Building, Suite 600 1492 Ponce de León Avenue San Juan, PR 00907-4127 Tel. (787) 723-8403 Fax: (787) 724-2604 INVESTMENT
GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF INSURANCE, SECURITIES AND BANKING 810 F IRST S TREET, NE, S UITE 701 Washington, D.C. 20002 Application for Continuing Care Retirement Community License
500 N. Western Avenue Suite 100 Sioux Falls, SD 57104 Telephone 605.367.5353 Fax 605.367.5394 E-Mail: firstname.lastname@example.org OR email@example.com SECTION 1: APPLICATION CHECKLIST
APPLICATION FOR A LICENCE TO ACT AS AN INSOLVENCY PRACTICTIONER Pursuant to The Insolvency Act 2003 (the ACT ), Section 475(1) This application form should be read in conjunction with: - the Insolvency
THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 Office of the Professions, State Board for Engineering and Land Surveying PHONE: 518-474-3817 ext. 140 FAX: 518-473-6282
INSURANCE PRUDENTIAL RULES In terms of Section 50 of the NBFIRA Act Section 43 on Licensing IAF3 New Licence Application Form: Insurance, Pension fund and Health Business Intermediaries Natural and Legal