Fillable OFFICE OF COMMISSIONER OF INSURANCE John F. King, (Georgia Technology Authority)

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OFFICE OF COMMISSIONER OF INSURANCE John F. King, (Georgia Technology Authority)

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OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
John F. King, Commissioner
www.oci.ga.gov
Phone: 855-235-5174 ◊ E-mail: GAInslicensing@psionline.com
AGENTS LICENSING
GID-103-AL JUL2019
RESIDENT INSURANCE LICENSE APPLICATION
Page 1 of 2
ONLINE APPLICATION SERVICES
www.sircon.com/georgia
LICENSURE INFORMATION
www.oci.ga.gov
SCHEDULING AN EXAMINATION
www.pearsonvue.com or 1-800-274-0488
License Number
I
.
LICENSE
NEW TEMPORARY LICENSE *
TEMPORARY LICENSE RENEWAL*
REINSTATEMENT
II. TYPE OF LICENSE
III. CLASS (ES) OF INSURANCE
AGENT
ADJUSTER
COUNSELOR
CROP HAIL ADJUSTER
FRATERNAL AGENT
LIMITED HEALTH COUNSELOR
LIMITED SUBAGENT **
PUBLIC ADJUSTER
SURPLUS LINES BROKER
WORKERS
COMPENSATION ADJUSTER
LIFE, ACCIDENT & SICKNESS
ACCIDENT & SICKNESS
CASUALTY
CREDIT
LIFE
LTD. COUNSELOR-HEALTH
PERSONAL LINES
PROPERTY
PROPERTY AND CASUALTY
TITLE
TRAVEL ACCIDENT & SICKNESS
TRAVEL TICKET
VARIABLE PRODUCTS
WORKERS COMPENSATION
(FOR ADJUSTER)
* FOR A
TEMPORARY
LICENSE:
1.
NAME OF SPONSORING INSURANCE COMPANY
NAIC COMPANY CODE
2.
NAME OF SUPERVISING AGENT
LICENSE NUMBER
** FOR A
LIMITED
SUBAGENT
LICENSE:
3.
NAME OF SPONSORING AGENT
LICENSE NUMBER
APPLICANT’S INFORMATION:
4.
FULL LEGAL NAME:
(FIRST)
(MIDDLE)
(LAST)
(SUFFIX)
5.
SOCIAL SECURITY NUMBER:
6.
DATE OF BIRTH:
7.
SEX:
8.
RESIDENCE ADDRESS (PHYSICAL LOCATION):
(STREET AND NUMBER REQUIRED)
(CITY)
(STATE)
(ZIP)
(COUNTY)
(HOME TELEPHONE)
9.
RESIDENCE MAILING ADDRESS:
(IF OTHER THAN 8)
(INCLUDE P.O.BOX, STREET, CITY, STATE, ZIP CODE AND COUNTY)
10.
BUSINESS ADDRESS (PHYSICAL LOCATION):
(BUSINESS NAME)
(STREET NUMBER, STREET NAME, SUITE NUMBER)
(CITY)
(STATE)
(ZIP)
(COUNTY)
(BUSINESS TELEPHONE)
11.
BUSINESS MAILING ADDRESS:
(IF OTHER THAN 10)
(INCLUDE BUSINESS NAME, P.O.BOX, STREET, CITY, STATE, ZIP CODE AND COUNTY)
12.
FAX NUMBER:
EMAIL:
MANDATORY QUESTIONNAIRE:
13.
Does any insurer or general agent claim that you are indebted or had an agency contract canceled for indebtedness?
If yes, attach a letter from the insurer/agent to whom you are indebted giving full details.
YES
NO
14.
Have you ever been convicted of or are you currently charged with a felony?
If yes, attach certified copies of ALL plea agreements and court orders.
YES
NO
15.
Have you been convicted of or are you currently charged with the commission of any crime or pled nolo contendere in a criminal proceeding or
have you received first offender treatment or had adjudication of guilt withheld in a criminal proceeding, other than a minor traffic offense?
If yes, attach a supplement giving full details and attach certified copies of plea agreements and all court orders.
YES
NO
16.
Have you ever been refused or had suspended or revoked an insurance license in any state?
If yes, attach supplement giving full details and attach certified copies of all orders.
YES
NO
17.
Have you ever had any other administrative action instituted against you by the insurance regulatory authority of any state?
If yes, attach supplement giving full details and attach certified copies of all orders.
YES
NO
18.
Have you ever:
A. Had any license, permit, authorization, registration, or privilege denied, refused, revoked, suspended, limited, withdrawn,
or restricted?
YES
NO
B. Had any other disciplinary action taken against you?
YES
NO
C. Had the renewal of any license, permit, authorization, registration, or privilege refused by any authority pursuant to a
disciplinary proceeding other than that of the Insurance Commissioner.
YES
NO
D. Failed to notify the Insurance Commissioner in writing within sixty days of the occurrence of any event listed above.
YES
NO
If yes to any of the above, attach supplement giving full details and attach certified copies of all orders.
www.oci.ga.gov
OFFICE OF COMMISSIONER OF INSURANCE
AGENTS LICENSING
GID-103-AL JUL2019
RESIDENT INSURANCE LICENSE APPLICATION
Page 2 of 2
19.
Have you ever withdrawn an application for any business or professional license granted by any licensing authority?
If yes, attach supplement indicating the type of license, reason for withdrawal and the licensing authority.
YES
NO
20.
Do you or will you maintain an office as an insurance agent, adjuster, counselor, limited subagent or surplus lines broker in this state?
YES
NO
21.
Have you ever held an insurance license issued by this department?
If yes, list license type, number and last year licensed. ___________________________________________
YES
NO
22.
Have you held an insurance license of any type in any other state within the last 5 years?
If yes, attach an original clearance letter from prior state dated within 90 days.
YES
NO
23.
Have you completed and attached the notarized Citizenship Affidavit Form GID-276-EN to this application?
If not, you must do so in order for this application to be processed. The form is available at www.oci.ga.gov.
YES
NO
!!!
Submit Application” WITH ALL” required documents
!!!
Check box to confirm that ALL required documents are attached.
APPLICANT’S ATTESTATION:
I HEREBY CERTIFY THAT ALL THE INFORMATION IN THIS ENTIRE APPLICATION, FORM GID-103, INCLUDING ANY DOCUMENTS ATTACHED HERETO, IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I FURTHER CERTIFY THAT I HAVE ATTACHED ALL APPLICABLE SUPPLEMENTARY DOCUMENTS AND I
UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REGULATORY ACTION. I HEREBY GIVE MY PERMISSION FOR A CRIMINAL BACKGROUND INVESTIGATION.
SIGNATURE OF APPLICANT
DATE
NOTARY
SEAL
&
SIGNATURE
REQUIRED
Sworn to and Subscribed before Me this _______ day of _________________, ________.
( Seal )
In the County of __________________________, State of _________________________.
________________________________________ ___________________________
(Signature Of Notary Public) (My Commission Expires)
SPONSOR’S CERTIFICATE:
REQUIRED IF APPLYING FOR A TEMPORARY LICENSE OR LIMITED SUBAGENT LICENSE ONLY
I HAVE READ THE QUESTIONS AND ANSWERS GIVEN BY THIS APPLICANT HEREIN, AND HAVE MADE A DILIGENT INQUIRY AND INVESTIGATION RELATIVE TO THIS
APPLICANT’S CHARACTER, IDENTITY, RESIDENCE, EXPERIENCE AND INSTRUCTION. THE FINDINGS OF SAID INQUIRY AND INVESTIGATION ENABLE ME TO
CERTIFY AS FOLLOWS: (1) SAID ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF; (2) I AM SATISFIED THAT THE APPLICANT IS TRUSTWORTHY
AND QUALIFIED TO ACT AS OUR TEMPORARY AGENT OR LIMITED SUBAGENT AND TO HOLD HIMSELF OR HERSELF IN GOOD FAITH TO GENERAL PUBLIC AS SUCH
TEMPORARY AGENT OR LIMITED SUBAGENT; (3) WE DESIRE THAT THE APPLICANT BE LICENSED AS INDICATED TO REPRESENT US IN THE STATE OF GEORGIA.
Name of insurance company if applying for temporary license
or sponsoring agent if applying for limited subagent license
Name and Title of company official for temporary license or
name of sponsoring agent for limited subagent
Name
Title
Signature of company official for temporary license or
sponsoring agent for limited subagent license
Signature
EFFECTIVE 7-1-2012, ALL NEW LICENSES, EXCLUDING TEMPORARY LICENSES, WILL BE ISSUED ON A BIENNIAL BASIS
.
INSTRUCTIONS:
BOND
COUNSELOR, PUBLIC ADUSTER, SURPLUS LINES BROKER, or LIMITED GROUP HEALTH COUNSELOR applications must include the
appropriate BOND with this application.
CITIZENSHIP AFFIDAVIT
Form GID-276-EN verifying lawful presence of all new and renewal applicants must be submitted with this application for processing.
FINGERPRINTS
All New Applicants, excluding active licensees and individuals that apply for reinstatement within 6 months of expiration date, shall
be required to submit electronic fingerprints for a criminal background check. The applicant shall bear the cost for electronic
fingerprinting. Fingerprinting information can be found on the department’s website.
VARIABLE PRODUCTS
A current U-4/WEB CRD status report showing NASD Series 6 or 7 approved registrations must be submitted with this application.
COUNSELOR LICENSE
Attach supplement showing evidence of 5 years experience as an agent, subagent or adjuster or in some other phase of the
insurance business or sufficient teaching experience or educational qualifications.
FEE SCHEDULE:
AGENT LICENSE
(FOR ONE CLASS/MAJOR LINE OF INSURANCE)
$115 ($100 LICENSE, $15 APPLICATION) THE AGENT LICENSE FEE IS
BASED ON CLASSES OF INSURANCE AND LICENSES REQUESTED)
TEMPORARY LICENSE
$ 75 ($50 LICENSE, $15 APPLICATION, $10 CERTIFICATE OF AUTHORITY)
LIMITED SUBAGENT LICENSE
$120 ($100 LICENSE, $15 APPLICATION, $5 SUBAGENT CERTIFICATE
OF AUTHORITY)
ADJUSTER, COUNSELOR & LIMITED GROUP HEALTH COUNSELOR LICENSES
$115 ($100 LICENSE, $15 APPLICATION)
SURPLUS LINES BROKER LICENSE
$615 ($600 LICENSE, $15 APPLICATION)
MAKE CHECKS OR MONEY ORDERS PAYABLE TO PSI Services LLC / GEORGIA INSURANCE DEPT.
Regular Mailing Address With Payments:
PSI Services LLC,
P.O. Box 742983, Atlanta, GA 30348-2983
Overnight Mailing Address With Payments:
Bank of America, ATTN: PSI Services LLC Box 742983,
6000 Feldwood Road, Atlanta, GA 30349
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OFFICE OF COMMISSIONER OF INSURANCE John F. King, (Georgia Technology Authority)

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Completed 10 August 2020

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