Office of Insurance and Safety Fire CommissionerRalph T. Hudgens
Commissioner
Home Agents Agencies Insurers Fire Marshal Industrial Loan Consumer Services Premium Tax Legal Fraud

Third Party Administrators 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 #: GID-051-NT (same as GID-051-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2012
Title: Application For License As An Administrator
This form is submitted by companies to make application as a TPA Administrator. Instructions are included with the form. 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. 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.

Form #: GID-052-NT (same as GID-052-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2012
Title: Biographical Statement And Affidavit
This form is used to provide biographical information on individuals where required. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-053-NT (same as GID-053-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2011
Title: Authority For Release Of Information
This form is submitted to authorized the Office of Commissioner of Insurance to conduct a background investigation. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-054-NT (same as GID-054-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2011
Title: Service Of Process Consent And Agreement
This form is used to designate the person to be served for transactions that require official notification. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-055-NT (same as GID-055-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2011
Title: Resolution Form
This form is used by a corporation to designate officers empowered to act on behalf of the corporation. The corporate seal must be affixed to the document. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-056-NT (same as GID-056-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2011
Title: Financial Statement
This form is used to provide annual financial information about the entity. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-057-NT (same as GID-057-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2011
Title: Bond
This form is used by Administrators to meet the established bond requirements. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-242-NT (same as GID-242-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2013
Title: Third Party Administrator Notice Of Exemption
This form is used to claim an annual exemption as a Third Party Administrator. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-276-EN This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2014
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.

Form #: GID-363-NT DEC2013 This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2014
Title: TPA Annual Statements Filing Instructions And Check Sheet
Contains information pertaining to the requirements of Third Party Administrators for filing with the department. This Check Sheet is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: Third Party Administrator (TPA) Exemption Letter This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2013
Title: Third Party Administrator (TPA) Exemption Filing Requirements
This document explains the applicable requirements for filing for an exemption.

EmploymentE-VerifySitemapTechnical Contact10/2/2014 4:23:51 AM-172.16.0.32Contact UsPrivacy PolicyLaws & Regs