Form Gid-214-Pt - Report Of Person(S) Procuring Insurance From Unauthorized Insurers Premium Tax Affidavit - Georgia Insurance Department

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OFFICE OF COMMISSIONER OF INSURANCE

COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER•COMPTROLLER GENERAL

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

REPORT OF PERSON(S) PROCURING INSURANCE FROM UNAUTHORIZED INSURERS

GID-214-PT Jan11

PREMIUM TAX AFFIDAVIT

FOR THE 30 DAYS ENDING

________________________

the undersigned do hereby depose and state that I am the duly authorized

__________________

___________________________

(the "Reporting Person(s)") and that such Person(s) has (have) procured, caused to be procured, continued or renewed the insurance listed below with unauthorized insurers upon

subjects of insurance resident, located, or to be performed within this state, other than insurance procured through a surplus lines broker or exempted from Article 2 of the Georgia

Insurance Code under Code Section 33-5-35:

CODE*

See Attachment

(Transaction Type)

Initial Entry

___

Additional Premium

___

Endorsement

___

Return Premium

___

Renewal Premium

___

Other _______________________________

Policy

Effective

Name and Address

Subject of

General

Code*

Amount of

Number

Date

of Insurance Co.

of Insured(s)

Insurance

Description

Premium

Tax

$0.00

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

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