Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697628007350.pdf (Antigua and Barbuda)
APPLICATION FOR RENEWAL OF REGISTRATION AS INSURANCE AGENT Full Name of Applicant (individual/Firm/Company) Address Email Contact No.

Name of Company for which the Applicant is registered as Agent Renewal Year ENDORSEMENT OF THE INSURANCE COMPANY I certify that the Applicant is contracted by ………………………….and hereby endorse the renewal of the Certificate of Registration as an Insurance Agent.
Signature Date Title (Affix Official Stamp) To be signed by the Chief Executive Officer/Manager of the Company/Principal Representative PARTICULARS This serves to confirm that the actions indicated below have been taken by the above-stated in Applicant in the areas listed on this form for the current year compliance with the Insurance Act, Act No.

13 of 2007. and is 1.


Within 4 months of close of Applicant’s Financial Year submission of (i) (ii) a copy of the audited financial statements; an analysis of premiums due but not paid to its principal or to each insurer, as the case may be, listing the aging of the sums outstanding.

Date Complied This document may contain information that is confidential, proprietary, privileged and/or otherwise protected by law.
Any unauthorized disclosure, dissemination, copying or other use either in whole or in part, of this document is prohibited.

If you are not the intended recipient, please notify the Financial Services Regulatory Commission (FSRC) immediately.

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That the Applicant has advised the Superintendent of Insurance, in writing, of all changes in the Applicant’s share holdings, officers, agency agreement, power of attorney, or in particulars submitted for approval of licensing or in subsequent notifications to Superintendent of Insurance, and the Superintendent of Insurance has given written approval having been given notice of such changes.

Date Complied I/We enclose check No payment of the prescribed fee.
dated as evidence of I certify that I have read all the above declaration(s) and that they are true and accurate in all respects.

Date Signature Title Director/General Manager/Company Secretary (If the application is on behalf of a firm or company affix official stamp) N.B.
(1) Where any of the above requirements do not apply to a company by virtue of the nature of its business please state “Not Applicable” in the space provided for indicating date complied with; (2) There is a late registration fee which shall be calculated at the rate of five per centum of the ordinary registration fee for each month or part of a month after the expiry of the prior registration, in accordance with Section 91(3) of the Act.
This document may contain information that is confidential, proprietary, privileged and/or otherwise protected by law.

Any unauthorized disclosure, dissemination, copying or other use either in whole or in part, of this document is prohibited.

If you are not the intended recipient, please notify the Financial Services Regulatory Commission (FSRC) immediately.