Form Gid-212-Pt - Surplus Line Broker'S Quarterly Premium Tax Affidavit - Georgia Insurance Department

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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 916, West Tower, Atlanta, GA 30334

Phone: 404-656-7553 ◊ E-mail: premiumtax@oci.ga.gov

PREMIUM TAX

GID-212-PT JAN 11

SURPLUS LINE BROKER’S QUARTERLY PREMIUM TAX AFFIDAVIT

(previously GID-FO-PT-1)

SLB License No.

FOR THE QUARTER ENDING

______________

Surplus Line Broker

deposes and states that the insurance transactions listed below were issued under the following terms:

(Name)

1. The insured or insured's agent has made an effort to procure the desired insurance coverage or benefits from authorized insurers.

2. The insurance was procured from insurers which meet the financial condition requirements of O.C.G.A.§ 33-5-25.

3. The said contracts have been solicited and written in strict compliance with the Georgia Surplus Line Insurance law, bear the name of the surplus line broker who procured

it and have printed or written thereon the following statement. "This contract is registered and delivered as a surplus line coverage under the Surplus Line Insurance Law,

O.C.G.A. Chapter 33-5."

See Attachment

_____________________

CODE* (Transaction Type)

Inial Entry ______

Additional Premium ______

Endorsement ______

Return Premium ______

Renewal Premium ______

Other

Policy

Effective

Date Premiums

Name and Address

Subject of

Code*

Amount of

Number

Date

Were Received

of Insurance Co.

of Insured(s)

Insurance

Premium

Tax

Page Totals $

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this

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office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056.