Application For Insurance Broker'S License
Application For Insurance Broker'S License
Department of Finance
INSURANCE COMMISSION
Manila
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.)
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. _____________________
______________________________________________________________________________
(a) Attach certified true copy each of the Certificate of Registration, Articles of Partnership,
Association or Incorporation and By-Laws; and
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. _______________________________________________________
______________________________________________________________________________
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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).
17. State below the names and addresses of four (4) responsible persons for reference.
__________________________________
Signature of Applicant
TIN : ____________________________
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AFFIDAVIT OF VERIFICATION
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
Notary Public
IC-LLI-DP-003-F-02
Rev.0