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Third Party Administrator Forms



Form #GID-051-NT 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.
PID:649-SID:1015-FN:GID-051-NT.pdf

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:1024-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:1017-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:1018-FN:GID-055-NT.pdf

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:1025-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:1019-FN:GID-057-EN.pdf

Form #GID-242-NT 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.
PID:653-SID:1020-FN:GID-242-EN.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:1689-FN:GID-276-EN.pdf

Form #GID-363-NT This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Financial OversightPublished: 2018
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.
PID:647-SID:1013-FN:GID-363-NT.pdf

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