Office of Insurance and Safety Fire CommissionerRalph T. Hudgens
Commissioner
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Health Maintenance Organizations (HMO) Forms

ATTENTION: TO ALL NEW APPLICANTS - EFFECTIVE 1/1/2012. 
In accordance with state law, beginning January 1, 2012, the Office of Insurance and Safety Fire Commissioner will be changing its procedures regarding the verification of lawful presence of persons applying for all licenses, permits, registrations and certificates. Please click HERE for more information.

ATTENTION:
 We have NEW IMPORTANT payment procedures. Please view them HERE.


Form #: CHECKLIST - Health Entities This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2014
Title: Health Entities Checklist
Provides a guide to the requirements for the 2014 annual filing.

Form #: GID-003-RS This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2010
Title: Appointment of Attorney-in-fact by Insurer
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-010-RS This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2012
Title: Application for Renewal of Certificate of Authority
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-011-RS with Reference Guide This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2010
Title: Insurance Company Annual Statement for Publication
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-016-RS This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2010
Title: Affidavit of Investment by Domiciliary Insurers
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-018-RS This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2010
Title: Initial Statement of Beneficial Ownership of Equity Securities
This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-253-RS This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2013
Title: Fees Statement And Transmittal Voucher
Serves as the annual renewal fees proof of payment. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-276-EN This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2013
Title: Citizenship Affidavit
Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

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