Form Gid-214-Pt - Report Of Person(S) Procuring Insurance From Unauthorized Insurers 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•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

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 $

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

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

GRAND TOTAL (Must agree with detail Grand Total)

filed.

0.00

GID #

Contact Name

Sworn to and subscribed before me

Name of Reporting Person(s) (Please Print or type name)

Street Address

this

day of

City

State / ZIP

Deponent (Authorized Representative of Reporting Person)

Contact Phone #

Notary Public

New Address? Check Box

(SEAL)

Email Address

In accordance with the provisions of Georgia Insurance Code Section 33-5-33, all taxes due to the State of Georgia for insurance procured directly from unauthorized

insurers are required to be paid coincidentally with the filing of this report and a check in the amount of such taxes due should accompany this report.

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.