OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
Ralph T. Hudgens, Commissioner
2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334
404-656-2074 ◊
770-344-4878 ◊
RegServices@oci.ga.gov
Phone:
Fax:
Email:
REGULATORY SERVICES
GID-007-RS JUL2014
OFFICIAL HAVING SUPERVISION OF INSURANCE IN THE STATE OF DOMICILE
Name of Company
_____________________________________________________________________________________________________________________
Street Address
_________________________________________________________________________________________________________________________
City
State
Zip Code
State of Georgia Insurance Commissioner, Atlanta, Georgia
A.
The aforementioned company is applying for admission to the State of and seeks authority to write the classes shown below. The
names of each class are: (1) Life, Accident and Sickness; (2) Property, Marine and Transportation; (3) Casualty; (4) Surety; and (5)
Title (Section 33-7-8, Georgia Insurance Code). For a definition of each kind, see Code Sections 33-7-2, 33-7-3, 33-7-4, 33-7-5,
337-6, and 33-7-8.
1.
2.
3.
4.
5.
B
Applicant is a____________________________________________ company. It is authorized to write each of the classes in
.
(stock, mutual, assessment, etc.)
section A in this State except ____________________________________________________________________________.
C.
A like _____________company applying for authority to write the same classes of business in this State would be required to
have:
Paid up capital…………………………………………………… $
Surplus over all liabilities………………………………..……….
Surplus to policyholders, including capital stock………………...
A deposit in Georgia……………………………………………...
A deposit in this State (life, accident & sickness)………………..
A deposit in this State (excluding Workers’ Comp.).…………….
A deposit in this State (including Workers’ Comp.)……………...
This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format.
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