Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697633386278.pdf (Antigua and Barbuda)
APPLICATION FOR RENEWAL OF REGISTRATION AS INSURANCE SALES REPRESENTATIVE 1.

Full name of Applicant Mr./Mrs./Miss 2.

Address 3.

Name of Insurance Company for which /with whom the Applicant is registered as Sales Representative 4.

Address 5.

Renewal Year 6.

Pursuant to Section 89 of the Act, I confirm that I am not: a. an un-discharged bankrupt; b. I have not been found by a court to be of unsound mind or is so certified under the law relating to mental health.

7.
7.

Endorsement of the Insurance Company: I certify that the information in item 3 above is true and correct.

Signature Date Title (Affix Official Stamp) To be signed by the Chief Executive Officer/Manager of the Company/Principal Representative 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.

I certify that to the best of my knowledge and belief all of the information given in this application is true and correct.

Date Signature of Applicant I enclose check No Dated as evidence of payment of the prescribed fee.
Note: 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 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.