Form Gid-212-Pt - Surplus Line Broker'S Quarterly Premium Tax Affidavit - Georgia Insurance Department Page 4

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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)

TOTAL PREMIUMS BY INSURANCE COMPANY

Name of Insurance Company/State

State

NAIC#

Total

Premium

Total premiums for each

insurance company reported

above must be provided.

Failure to do so will result in

an incomplete return and may

not be considered timely filed.

GRAND TOTAL (Must agree with detail Grand Total)

0.00

Sworn to and subscribed before me

Surplus Line Broker (Signature)

Contact Name

this

day of

Street Address

Name of Surplus Line Broker (Please Print)

City

State / ZIP

Notary Public

Broker License #

Contact Phone #

(SEAL)

Date Licensed

New Address? Check Box

Email Address

In accordance with the provisions of Georgia Insurance Code Section 33-5-31,

surplus line brokers shall remit all taxes due on or before the fifteenth day of April, July, October and January at the time his or her quarterly affidavit is submitted.

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 4 of 4

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