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Health Plan Purchasing Cooperative



Form #GID-052-NT 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.
PID:656-SID:1430-FN:GID-052-NT.pdf

Form #GID-053-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
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.
PID:650-SID:1766-FN:GID-053-NT.pdf

Form #GID-055-NT 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.
PID:651-SID:1768-FN:GID-055-NT.pdf

Form #GID-057-NT (same as GID-057-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2019
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.
PID:652-SID:1428-FN:GID-057-EN.pdf

Form #GID-058-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
Title: Service of Process
Third Party Administrator Service of Process Form. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.
PID:1158-SID:3007-FN:GID-058-NT.pdf

Form #GID-080-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2012
Title: Application For License As A Health Plan Purchasing Cooperative (same as GID-80)
Application is hereby made for a License to operate as a Health Plan Purchasing Cooperative (“HPPC”) pursuant to the Laws of Georgia. 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, submit with the application the Citizenship Affidavit Form GID-276-EN which is required of persons making application for all licenses 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.
PID:747-SID:1545-FN:GID-080-NT.pdf

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