This document is an application for an insurance broker's license from the Republic of the Philippines Department of Finance Insurance Commission. It contains a 16 item application requesting information about the applicant such as personal details, experience, references, and errors and omissions insurance coverage. The applicant must sign an affidavit verifying the application information and submit required documents before the license will be considered.
This document is an application for an insurance broker's license from the Republic of the Philippines Department of Finance Insurance Commission. It contains a 16 item application requesting information about the applicant such as personal details, experience, references, and errors and omissions insurance coverage. The applicant must sign an affidavit verifying the application information and submit required documents before the license will be considered.
This document is an application for an insurance broker's license from the Republic of the Philippines Department of Finance Insurance Commission. It contains a 16 item application requesting information about the applicant such as personal details, experience, references, and errors and omissions insurance coverage. The applicant must sign an affidavit verifying the application information and submit required documents before the license will be considered.
This document is an application for an insurance broker's license from the Republic of the Philippines Department of Finance Insurance Commission. It contains a 16 item application requesting information about the applicant such as personal details, experience, references, and errors and omissions insurance coverage. The applicant must sign an affidavit verifying the application information and submit required documents before the license will be considered.
COMMISSION USE Verified by: ____________________ Accomplish this form legibly and fully in your own handwriting. This application will not be accepted unless Date: _______________________ all information called for are furnished. Processed by: _________________ This application must be accompanied with a documentary stamp which shall be affixed to the license Date: _______________________ being applied for. Approved by: __________________ Every applicant shall also file with the application a bond in such amount as may be determined by the Date: _______________________ Insurance Commissioner, but in no case less than Five Hundred Thousand Pesos ( P 500,000.00) and two (2) License Fee: P ________________ Errors and Omissions Insurance Policy (Professional Liability or Professional Indemnity Policy) as required O.R. No.: _____________________ under IMC No. 2-85 dated 7 August 1985. Date: ________________________
To the Insurance Commissioner:
The undersigned hereby applies for a license as insurance broker, pursuant to the provisions of Chapter IV of the Insurance Code, and in support of this application represents as follows:
1. Name of applicant:_______________________________________________________________ (If applicant is a partnership, association or corporation, Items 2 to 9 apply to the individual or person duly authorized to act for and in its behalf and whose name shall be stated in the license to be issued.)
2. (a) Date of Birth: ____________________ (b) Place of Birth: _______________________
(b) If a naturalized citizen of the Philippines, give date and place of naturalization and attach photostatic copy of certificate of naturalization. ___________________________________ _________________________________________________________________________
6. Have you ever been dishonorably discharged from any position of employment? ______________ If yes, state particulars. ___________________________________________________________
7. Have you ever been accused of any crime? __________________ If yes, attach copy of court’s decision.
8. Have you filed your income tax return for the preceding year? _________ If yes, attach proof of such filing, otherwise, give reason for not filing.
9. What experience and/or training have you had in the insurance business? State in what branches or kinds of insurance, in what capacity, and where and when engaged. _____________________ ______________________________________________________________________________
10. If applicant is a partnership, association or corporation:
(a) Attach certified true copy each of the Certificate of Registration, Articles of Partnership, Association or Incorporation and By-Laws; and
(b) State percentage of Filipino participation in the partnership, association or corporation as of
the date of this application. ________________________________________
11. Is the applicant (and the individual duly authorized to act in its behalf, if applicant is a partnership, association or corporation) duly covered by an Errors and Omissions Policy or Professional Liability or Professional Indemnity Policy? ___________ If yes, attach copy of the policy.
12. If the applicant is an alien individual or domestic enterprise which is a non-Philippine national, or more than 40% of the outstanding capital of which is owned or controlled by non-Philippine nationals, attach written authority from the Board of Investments, under Republic Act No. 5455, as amended by Executive Order No. 226 (The Omnibus Investments Code of 1987) to do business or engage in an economic activity in the Philippines.
13. Have you ever been licensed by this Office to act as insurance broker or agent? _________ If yes, please state the full circumstances. _________________________________________________ ______________________________________________________________________________
14. Are you an official stockholder or employee or an insurance company? ___________ If yes, state the name of the company and percentage of ownership, if any. ____________________________ ______________________________________________________________________________
15. Are you a licensed insurance agent? _____________ If yes, state the name/s of the insurance company/ies you represent. _______________________________________________________ ______________________________________________________________________________
2 16. In the blanks below, state how you have been occupied during the last ten years (without interruption) up to the date of this application, irrespective of whether employed or not. (Attach additional sheet, if necessary).
Inclusive Dates In what Reason for
Name of Employer Where Under Whom From – To Capacity Leaving
17. State below the names and addresses of four (4) responsible persons for reference.
Name Occupation Post Office Address
Executed this ___________ day of _________________________________, 20_____ at
____________________________________________.
__________________________________ Signature of Applicant
TIN : ____________________________
3 AFFIDAVIT OF VERIFICATION
Republic of the Philippines )
Province/City of _________) S.S.
I, ___________________, being duly sworn, depose and say that I am the person named in and who signed the foregoing application; that I know that the contents thereof and the statements made and answers to questions therein are true.
_____________________________ Signature of Applicant
SUBSCRIBED AND SWORN TO before me this _______ day of ______________________
20___, by the above-named applicant who exhibited to me his/her Community Certificate Tax No. ___________________________________ issued ______________________________, 20 _____ at _____________________________________.
Notary Public
Doc. No. ______
Page No. ______ Book No. ______ Series of 20 ______
