Insurers: All GID Forms for Regulatory Services

Office of Insurance and Safety Fire Commissioner

Ralph T. Hudgens

Commissioner

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Regulatory Services Insurance Forms

ATTENTION: TO ALL NEW APPLICANTS - EFFECTIVE 1/1/2012.

In accordance with state law, beginning January 1, 2012, the Office of Insurance and Safety Fire Commissioner will be changing its procedures regarding the verification of lawful presence of persons applying for all licenses, permits, registrations and certificates. Please click HERE for more information.

ATTENTION:

We have NEW IMPORTANT payment procedures. Please view them HERE.

Form #: Captive Insurance Company $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Filing Requirements Memo - same as CAP-1
Provides the requirements for filing as a Captive Insurance Company.

Form #: CHECKLIST - Fraternal Societies $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Fraternal Societies Checklist
Provides a guide to the requirements for the 2012 annual filing.

Form #: CHECKLIST - Health Entities $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Health Entities Checklist
Provides a guide to the requirements for the 2011 annual filing.

Form #: CHECKLIST - Life, Accident and Health Insurers $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Life, Accident and Health Insurers Checklist
Provides a guide to the requirements for the 2012 annual filing.

Form #: CHECKLIST - Property and Casualty Insurers $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Property and Casualty Insurers Checklist
Provides a guide to the requirements for the 2012 filing.

Form #: CHECKLIST - Title Companies $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Title Companies Checklist
Provides a guide to the requirements for the 2012 annual filing.

Form #: GID-003-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Appointment of Attorney-in-fact by Insurer
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-003-RS Memo $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2009
Title: Appointment of Attorney-in-fact by Insurer (Memo)
Memo regarding Appointment of Attorney-in-fact by Insurer

Form #: GID-004-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Appointment of Commissioner as Attorney-in-fact by Insurer
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-007-NT $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Vehicle Protection Warrantor - Notice and Registration - Annual Renewal Registration (same as EN-7)
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-007-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2001
Title: Official Having Supervision Of Insurance In The State Of Domicile
Form is to be completed by the supervising insurance official.

Form #: GID-010-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application for Renewal of Certificate of Authority
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-011-RS Memo $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2001
Title: Memo regarding Insurance company
Memo regarding Insurance company's Annual Statement for Publication

Form #: GID-011-RS with Reference Guide $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Insurance Company Annual Statement for Publication
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-016-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Affidavit of Investment by Domiciliary Insurers
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-018-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Initial Statement of Beneficial Ownership of Equity Securities
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-019-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Statement Of Changes In Beneficial Ownership Of Equity Securities
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-021-EN JAN2012 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For A License As An Insurance Premium Finance Company
This application form is required for Insurance Premium Finance Companies requesting approval for a license to operate in the State of Georgia. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-022-EN JAN2012 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For Renewal License As An Insurance Premium Finance Company
Annual Renewal Licensing form used by Premium Finance Companies. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-023-EN DEC09 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Biographical Questionnaire For Premium Finance Companies
The Biographical Questionnaire must be completed by Affiants of Premium Finance Companies. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-024-EN DEC09 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Annual Report Of Insurance Premium Finance Companies
Insurance Premium Finance Companies are required to file this form with the department annually. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-028-EN DEC09 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Insurance Premium Finance Company Bond
This bond is required of Insurance Premium Finance Companies to operate within the state. Instructions are included with the form. This bond form requires the Licensee's and Surety's seals to be affixed. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-032-NT $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application for License as a Prepaid Legal Services Sponsor
Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-033-NT (same as GID-33) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application for Renewal License as a Prepaid Legal Service Sponsor
Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-034 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Bond by Sponsor of Prepaid Legal Services Plan
Bond by Sponsor of Prepaid Legal Services Plan

Form #: GID-035 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Power to Sell and Assign Securities Deposited with the Commissioner of Insurance
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-036 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Resolution Form Authorizing Sale or Assignment
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-037 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Authorization Form For Sale or Assignment
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-037-C $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Assignment of Savings Share Certificate or CD
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-038 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Assignment of Savings Share Certificate or Certificate of Deposit
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-039 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Annual Report of Prepaid Legal Services Sponsor
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-040-EN DEC09 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Insurance Premium Finance Company Convenience And Advantage Form
This form is submitted by companies to request approval for operating as an Insurance Premium Finance Company within the state. Instructions are included with the form. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-041 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Biographical Questionnaire
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-042-RS Exhibit K $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Property and Casualty Insurers 384 Annual Report
This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-043-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Automobile Self-Insurer Bond Form
Automobile Self-Insurer Bond Form and Instructions

Form #: GID-044-RS Exhibit L - GA Business $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Georgia Property and Casualty Insurance Information (Exhibit L - GA Business Only)
This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-045-RS Exhibit L - Countrywide $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Georgia Property and Casualty Insurance Information (Exhibit L - Countrywide)
This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-051-NT (same as GID-051-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For License As An Administrator
This form is submitted by companies to make application as a TPA Administrator. Instructions are included with the form. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-052-NT (same as GID-052-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Biographical Statement And Affidavit
This form is used to provide biographical information on individuals where required. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-053-NT (same as GID-053-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Authority For Release Of Information
This form is submitted to authorized the Office of Commissioner of Insurance to conduct a background investigation. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-054-NT (same as GID-054-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Service Of Process Consent And Agreement
This form is used to designate the person to be served for transactions that require official notification. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-055-NT (same as GID-055-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Resolution Form
This form is used by a corporation to designate officers empowered to act on behalf of the corporation. The corporate seal must be affixed to the document. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-056-NT (same as GID-056-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Financial Statement
This form is used to provide annual financial information about the entity. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-057-NT (same as GID-057-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Bond
This form is used by Administrators to meet the established bond requirements. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-059-EN NOV09 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Continuing Care Provider and Facility Biographical Affidavit
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-060-EN NOV09 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Annual Statement for Continuing Care Provider and Facility
This form is completed annually for the Provider and the Facility. Included are three parts to this form comprising general interrogatories and the statement of financial condition. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-061-EN JAN2012 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For Certificate Of Authority As A Continuing Care Provider
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-061-EN NOV09 Instructions $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Instructions For Application For Certificate Of Authority As A Continuing Care Provider
This document explains the requirements for making Application For Certificate Of Authority As A Continuing Care Provider.

Form #: GID-063-PC (same as GID-63) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: DISCLOSURE STATEMENT
For Experience Rating Notification By Workers' Compensation Carriers.

Form #: GID-080-NT $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For License As A Health Plan Purchasing Cooperative (same as GID-80)
Application is hereby made for a License to operate as a Health Plan Purchasing Cooperative (“HPPC”) pursuant to the Laws of Georgia. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, submit with the application the Citizenship Affidavit Form GID-276-EN which is required of persons making application for all licenses in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-210-NT (same as GID-210-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Risk Retention Group Notice and Registration
Annual Risk Retention Group Notice and Registration. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form. You may fill it out on-line, print it and send it to us. Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-211-NT (same as GID-211-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Purchase Group Notice and Registration
Annual Risk Purchase Group Notice Registration. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-239-NT (same as GID-239-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Annual Renewal Check Sheet For Groups
Used by Groups to provide contact information specific to the Group. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-242-EN DEC09 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Third Party Administrator Notice Of Exemption
This form is used to claim an annual exemption as a Third Party Administrator. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-251-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Corporate Officers List
Use for reporting company officers, directors or trustees. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-253-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2010
Title: Fees Statement And Transmittal Voucher
Serves as the annual renewal fees proof of payment. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-254-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application for Renewal of Certificate of Authority for Group Self-Insurance Fund - same as GSF-2
This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-254-RS (same as GSF-2) Instructions $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2005
Title: Workers Comp Group SeIf-Insurance Fund Annual Statement Filing Instructions
This memo provides instructions for the Annual Statement Filing.

Form #: GID-255-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Automobile Application For Self-Insurance
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-256-NT (same as GID-256-EN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application for New and Renewal License As Pharmacy Benefits Managers
Application is hereby made for a License to operate as a Pharmacy Benefits Manager pursuant to the Laws of Georgia. Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-257-NT $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Verification of Coverage
Form includes requirements for Insurance Companies and Life Settlement Providers/Producers.

Form #: GID-259-RS (same as SYNOPSIS) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Synopsis Of Requirement To Form A Workers Compensation Group Self-Insurance Fund
Synopsis Of Requirement To Form A Workers Compensation Group Self-Insurance Fund.

Form #: GID-260-RS (same as GSF-IN) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Notice Of Intent To Form A Group Self-Insurance Fund
Notice Of Intent To Form A Group Self-Insurance Fund. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-261-RS JAN2012 (same as GSF-1) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For Certificate Of Authority For Group Self-Insurance Fund
Application is hereby for Certificate Of Authority For Group Self-Insurance Fund. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. Effective 1-1-2012, submit with the application the Citizenship Affidavit Form GID-276-EN which is required of persons making application for all licenses in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-262-RS (same as GSF-12) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Group Self-Insurance Surplus Bond
Group Self-Insurance Surplus Bond.

Form #: GID-263-RS JAN2012 (same as GSF-3) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For Membership In Group Self-Insurance Fund
Application For Membership In Group Self-Insurance Fund. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. Effective 1-1-2012, submit with the application the Citizenship Affidavit Form GID-276-EN which is required of persons making application for all licenses in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-264-RS (same as GSF-4) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Application For Termination Of Membership In Group Self-Insurance Fund
Application For Termination Of Membership In Group Self-Insurance Fund. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-265-RS (same as GSF-5) $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Applic To Serve As Officer Director Or Trustee Of Group Self-Insurance Fund
Application is hereby made to serve as Officer, Director or Trustee of Group Self-Insurance Fund.

Form #: GID-266-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application To Serve As Administrator Of Group Self-Insurance Fund - (same as GSF-6)
Application To Serve As Administrator Of Group Self-Insurance Fund. Effective 1-1-2012, submit with the application the Citizenship Affidavit Form GID-276-EN which is required of persons making application for all licenses in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-267-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Group Self-Insurance Bond (same as GSF-7)
Group Self-Insurance Bond.

Form #: GID-268-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Administers Fidelity Bond For Group Self-Insurance (same as GSF-8)
Administers Fidelity Bond For Group Self-Insurance.

Form #: GID-269-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Resolution Form Authorizing Sale Or Assignment Of Securities (same as GSF-9)
Resolution Form Authorizing Sale Or Assignment Of Securities. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-270-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Assignment of Savings Share Certificate or Certificate of Deposit (same as GSF-10)
Assignment of Savings Share Certificate or Certificate of Deposit. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-271-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Power To Sell and Assign Securities Deposited With The Commissioner of Insurance (same as GSF-11)
Power To Sell and Assign Securities Deposited With The Commissioner of Insurance (same as GSF-11). This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-278-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application For Certificate Of Authority For Captive Insurance Company - same as CAP-2
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-279-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Application To Serve As Administrator Of Captive Insurance Company - same as CAP-3
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-280-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Biographical Questionnaire For Captive Insurance Company - same as CAP-4
This form is required of persons holding a position as a company officer.

Form #: GID-281-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Resolution Form Authorizing Sale Or Assignment Of Securities - same as CPA-5
This form specifies the wording to be used in the resolution for authorizing sale or assignment of securities. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-282-RS $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Assignment Of Savings Share Certificate Or Certificate Of Deposit - same as CAP-6
This form is used to assign and transfer certificate funds to the Insurance Commissioner.

Form #: GID-283-NT $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: Pharmacy Benefits Manager Notice Of Affiliation
This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-NT-LS-1 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Filing Instructions For Life Settlement Licensure Renewals (same as GID-EN-LS-1) Instructions
Contains a Cover Letter and Instructions. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-NT-LS-1 $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2012
Title: New and Renewal Application for License as a Life Settlement Provider (same as GID-EN-LS-1)
This application is for new and renewal Life Settlement Provider applicants (which were previously separate forms). Refer to the instructions for new and renewal applications. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: Risk Purchasing Groups Annual Renewal Instructions $This is in the Adobe Portable Document format (pdf)\n$	Division: Regulatory Services	Published: 2011
Title: Purchasing Groups- Annual Renewal Memo (same as GID-211-EN Memo)
Memo for Annual Risk Purchasing Groups registration

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