Form Gid-215-Pt - Risk Retention Groups Quarterly Premium Tax Affidavit Page 4

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OFFICE OF COMMISIONER 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
RISK RETENTION GROUPS QUARTERLY PREMIUM TAX AFFIDAVIT
GID‐215‐PT JAN 12
Deponent/Authorized Representative 
of Reporting Person:
Reporting Person(s):
Deponent/Authorized Representative 
of Reporting Person's Position:
Quarter Ending Date:
Tax Year:
NAIC #:
Contact Name:
Street Address:
City:
State:
ZIP:
Contact Phone #:
New Address?
Email Address:
y
,
,
origin, sex, religion, age or disability in employment, 
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