Form Gid-007-Rs - Official Having Supervision Of Insurance In The State Of Domicile - Georgia Office Of Commissioner Of Insurance Page 2

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OFFICE OF COMMISSIONER OF INSURANCE

REGULATORY SERVICES

GID-007-RS JUL2014

OFFICIAL HAVING SUPERVISION OF INSURANCE IN THE STATE OF DOMICILE

A like______________________________________ company would be required to pay taxes, fees and other charges as follows:

Fees for Admission (Itemize) ……………………………………………… $ ________________________

Annual renewal Fees (Itemize)……………………………………………… $ ________________________

Fee for amending an existing company license……………………………… $ ________________________

Premium Taxes (State basis of computation in detail)…………………….… $ ________________________

All other charges, taxes and fees, including capital stock tax, fire marshal’s

tax, etc. (state kinds, basis of computation and dates payable)……………… $________________________

A bond would be required of a like_________________ company in the amount of ___________for purpose of

guaranteeing ____________________in accordance with Section__________________ of laws of this State.

A like ________________________________________company to be eligible for admission must, among other things, have been

in continuous operation for ___________________________. This requirement by ________________________________ .

(State Period of Time)

(Statute or Rule)

A like _____________________________________company to be eligible for admission would be required to furnish

An examination made by its own Insurance Department within a period of ______ years. This requirement is by_____________.

Exceptions to the statue or rule are:____________________________________________________________________

Print Name:

___________________________

Title:

______________

Signature:

___________________________

Date:

______________

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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