How do I complete the Appointment of Insurance Producer form?

The insurance company fills out and signs the appointment section, and the producer completes and signs the statement of agreement before a notary. Submit the completed form to the Office of the Commissioner of Insurance.

Do I need to sign the producer agreement before a notary?

Yes. The producer’s statement includes a “Subscribed and sworn to” jurat, so the producer signs before a notary. The company’s appointment section does not include a notary block.

Can I use a commissioned online notary for this form?

A commissioned online notary may be an option for the producer’s jurat. Confirm with the receiving agency or the Recorder of Deeds if unsure whether it will accept an online notarization.

Where do I submit the completed appointment form?

The form is addressed to the Office of the Commissioner of Insurance, Division of Banking, Insurance and Financial Regulation. Check with that office for current submission instructions.

Office of the Lieutenant Governor, VI · St. Thomas

Appointment of Insurance Producer

This two-part form lets an insurance company request authorization to appoint a producer and lets the producer agree to serve in the U.S. Virgin Islands.

Standard form~15 min to notarize

licensed online notary
~15 min average
Notarized PDF emailed

What you’ll need

Government-issued photo ID
Webcam-enabled device (laptop or phone)
This form, ready to upload as a PDF

Form previewView full PDF →

What this form is

An insurance company uses the appointment section to identify the producer, business address, insurance lines, and effective date, and to provide an authorized signatory’s signature. The producer completes the separate statement agreeing to serve and to follow the listed conditions. The form is submitted to the Office of the Commissioner of Insurance for approval and filing; the form cites Title 22, Sections 758 and 781 of the Virgin Islands Code.

Who needs it

An insurance company seeking to appoint a producer in the U.S. Virgin Islands and the producer agreeing to serve complete their respective sections.

Why it needs a notary

The producer signs the statement of agreement before a notary, who completes the form’s “Subscribed and sworn to” jurat; the company signatory section has no notary block.

How to get this notarized

1
Download The Form
Get the Appointment of Producer form from the Office of the Lieutenant Governor.
2
Complete Both Sections
The insurance company completes the appointment section; the producer completes the statement of agreement.
3
Book An Online Notary
Arrange a session with a commissioned online notary for the producer’s sworn statement.
4
Sign On Video
The producer signs the agreement during the online notarization; follow the notary’s instructions for the jurat.
5
Submit The Form
Send the completed form to the Office of the Commissioner of Insurance using its current submission instructions.

Preview the form

The blank PDF straight from Office of the Lieutenant Governor. Look it over, then upload your filled copy to start the notary session.

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You’ll need ID and a webcam.

A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.