Form Gid-212-Pt - Surplus Line Broker'S Quarterly Premium Tax Affidavit - Georgia Insurance Department Page 3

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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)

RETURN PREMIUMS AND CREDITS TO BE APPLIED: Return premiums and credits may only be applied to the surplus line broker who originally placed and

reported the business. List all returns and credits below - the "Quarter/Year Policy Reported" MUST be included to receive credit.

Policy

Effective

QTR\YR

Name and Address

Subject of

Code*

Amount of

Amount of Tax

Number

Date

Premiums Were

of Insurance Co.

of Insured(s)

Insurance

Premium

Reported

Page Totals $

(

)

$0.00

MAILING INSTRUCTIONS:

Grand Totals $

$0.00

IF YOU ARE PAYING BY CHECK: Mail your return and payment to Georgia Departement Of Insurance-Premium Tax Divison, P. O. Box 935134,

Atlanta, GA. 31193-5134. If you are sending payment overnight Delivery: Send your return and payment to Wachovia Bank, Georgia Department

of Insurance - Premium Tax Division, LockBox 935134, 3585 Atlanta Avenue, Hapeville, GA 30354

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

Page 3 of 4

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