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Pharmacy Benefit Managers



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.
PID:657-SID:1431-FN:GID-056-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:1528-FN:GID-057-EN.pdf

Form #GID-256-NT (same as GID-256-EN) This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2012
Title: Application for New and Renewal License As Pharmacy Benefits Managers
Application is hereby made for a License to operate as a Pharmacy Benefits Manager pursuant to the Laws of Georgia. 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.
PID:737-SID:1514-FN:GID-256-NT.pdf

Form #GID-276-EN This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2015
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.
PID:788-SID:1687-FN:GID-276-EN.pdf

Form #GID-283-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2012
Title: Pharmacy Benefits Manager Notice Of Affiliation
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:816-SID:1721-FN:GID-283-NT.pdf

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