Form Gid-212-Pt - Surplus Line Broker'S Quarterly Premium Tax Affidavit - Georgia Insurance Department Page 2

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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)

Policy

Effective

Date Premiums

Name and Address

Subject of

Code*

Amount of

Amount of Tax

Number

Date

Were Received

of Insurance Co.

of Insured(s)

Insurance

Premium

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.