COMMONWEALTH OF PUERTO RICO

OFFICE OF THE COMMISSIONER OF INSURANCE

INTERNATIONAL INSURER/REINSURER APPLICATION FOR

RENEWAL OF THE CERTIFICATE OF AUTHORIZATION

GENERAL INSTRUCTIONS

In accordance with Article 61.230(2) of the Insurance Code of Puerto Rico and Article 12

of Rule LXXX, which governs the Operations of International Insurers and/or

Reinsurers, all licensed international insurers/reinsurers shall renew its Certificate of

Authority annually, on or before June 30

, immediately following the date of issue or

renewal. Payment of corresponding charges must be in the form of money order or a

certified check, payable to the Secretary of the Treasury of Puerto Rico. In addition, and

pursuant to the governing laws and regulations of the Insurance Code of Puerto Rico,

the Commissioner has the discretion and powers to refuse to renew, revoke or suspend

the authorization of an International Insurer/Reinsurer. The Commissioner of

Insurance may also impose fines and/or penalties, and refuse to further renew, revoke

or suspend the certificate of authorization of an International Insurer/Reinsurer, if it is

not renewed by June 30th.

This form must be filled out in its entirety and when submitted, it should have attached,

all material requested, together with the corresponding payment. A response to each

item(s) is necessary in order for your application to be considered complete. If any

question(s) is inapplicable to your particular situation, please clearly indicate so by

marking “N/A” in the space provided. Fields marked with an (*) are required fields.

If the applicant is not organized under the laws of a state of the United States of

America, every document submitted shall be authenticated by a United States Consul or

certified with the Apostille of the Hague Convention of October 5, 1961.

Renewal Forwarding Postal Address for the Office of the Commissioner of Insurance of

Puerto Rico: B5 Tabonuco Street, Suite 216, PMB 256, Guaynabo, Puerto Rico 00968-

3029.

PLEASE TYPE ALL INFORMATION

INTERNATIONAL INSURER/REINSURER’S NAME: ____________________________________________________________________

FORM FOR RENEWAL OF THE CERTIFICATE OF AUTHORITY FOR THE YEAR: __________________________________________

PUERTO RICO INTERNATIONAL INSURANCE CENTER

Office of the Commissioner of Insurance FORM CIS RNW

Commonwealth of Puerto Rico Page 2 of 4

B5 Tabonuco Street, Suite 216

PMB 356

Guaynabo, PR 00968-3029

SECTION A: GENERAL INFORMATION

We submit the following information in compliance with the laws and regulations of

Chapter 61 of the Insurance Code of Puerto Rico, in order to obtain the renewal of our

certificate of authority to transact insurance business as an international

insurer/reinsurer for the year ____________.

1. Name, address and additional contact information for of the International

Insurer/Reinsurer entity: *

Name: ____________________________________________________________

Postal Address: Headquarters Address:

_______________________________ ______________________________

Telephone: ________________________ Fax: ________________________

Email: _______________________________________________________________

2. Corporate Id Number (FEIN Number):* _________________________________

3. NAIC Group Number (if applicable): ___________________________________

4. Name, address and additional contact information for the authorized Principal

Representative: *

Name: ____________________________________________________________

Address: ____________________________________________________________

____________________________________________________________

Telephone: ________________________ Fax: ________________________

Email: _______________________________________________________________

5. Name, address and additional contact information for the individual(s) to be

contacted regarding this application:*

Name(s): ____________________________________________________________

____________________________________________________________

Address: ____________________________________________________________

____________________________________________________________

Telephone: ________________________ Fax: ________________________

Email: _______________________________________________________________

INTERNATIONAL INSURER/REINSURER’S NAME: ____________________________________________________________________

FORM FOR RENEWAL OF THE CERTIFICATE OF AUTHORITY FOR THE YEAR: __________________________________________

PUERTO RICO INTERNATIONAL INSURANCE CENTER

Office of the Commissioner of Insurance FORM CIS RNW

Commonwealth of Puerto Rico Page 3 of 4

B5 Tabonuco Street, Suite 216

PMB 356

Guaynabo, PR 00968-3029

6. Indicate type of authorization being renewed (please check):

____ Class 1 ____ Class 2 ____ Class 3

____ Class 4 ____ Class 5

7. Please provide any information of any business other than insurance business that

the International Insurer/Reinsurer proposes to carry: (Please use a separate sheet, if

necessary.)*

_____________________________________________________________________

SECTION: FEES

Pursuant to Article 61.050(10) Rico and Article 12 of Rule LXXX of the Insurance Code

of Puerto, the International Insurer/Reinsurer will pay, on the date of each renewal, on

or before June 30

, an annual contribution pursuant to the ranges of written premium

and/or assumed premium set forth as follows:

PREMIUMS WRITTEN/ASSUMED

AMOUNT

TO BE PAID

1. No more than $25,000,000

$5,000.00

2. More than $25,000,000 but less than $50,000,000

$10,000.00

3. More than $50,000,000 but less than $75,000,000

$20,000.00

4. More than $75,000,000 but less than $100,000,000

$35,000.00

5. More than $100,000,000 but less than $150,000,000

$50,000.00

6. More than $150,000,000 but less than $250,000,000

$65,000.00

7. More than $250,000,000

$75,000.00

Please indicate check number and amount of annual contribution paid: *

Check Number: ________________________ Amount: ________________________

INTERNATIONAL INSURER/REINSURER’S NAME: ____________________________________________________________________

FORM FOR RENEWAL OF THE CERTIFICATE OF AUTHORITY FOR THE YEAR: __________________________________________

PUERTO RICO INTERNATIONAL INSURANCE CENTER

Office of the Commissioner of Insurance FORM CIS RNW

Commonwealth of Puerto Rico Page 4 of 4

B5 Tabonuco Street, Suite 216

PMB 356

Guaynabo, PR 00968-3029

SECTION D: CERTIFICATION

I certify that the information given in this application is true and correct and that all

estimates given are true estimates based upon the facts that have been carefully

considered and assessed. Furthermore, I affirm that pursuant to Article 61.050(9), the

applicant shall notify the Commissioner of Insurance in an expedited manner and in

writing, of any change in the information submitted as part of this application within

ten (10) days of said change.

If applicant is a Protected Cell International Insurer, I further acknowledge that all

financial records of the Protected Cell Company, including records pertaining to

protected cells, shall be available for inspection or examination by the Commissioner or

the Commissioner’s designee.

Name: ________________________________ Date: ________________________

Signature: ______________________________________________________________

(DIRECTOR)

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Affidavit No. ___________

Personally appeared before me the above named ____________________________

personally known to me, who, being duly sworn, deposes and says that he/she

executed the above instrument and that the statements and answers contained therein

are true and correct to the best of his/her knowledge and belief.

Subscribed and sworn to before me this _______ day of ________________, 20__

______________________________

NOTARY PUBLIC