Gid 103 Al Form PDF Details

The GID-103-AL, a comprehensive form issued by the Office of the Commissioner of Insurance in Georgia, serves as the cornerstone for those entering the state's insurance market as professionals. Tailored for a wide spectrum of applicants, it facilitates the application process for various insurance-related roles – from agents and adjusters to counselors and subagents, encompassing both temporary positions and more permanent roles. This form is not just a means to apply for a new license but also accommodates those seeking renewals, reinstatements, and changes in the class(es) of insurance one is licensed to deal with. Beyond personal and professional details, it mandates disclosures relating to past legal and professional conduct, thereby upholding the Commissioner's commitment to integrity within the industry. Additionally, it addresses the need for a sponsoring insurance company or agent in certain cases, reflecting the form's role in ensuring applicants are backed by established entities within the sector. The completion and submission of this form, inclusive of all necessary supplemental documents and applicable fees, is a critical step for candidates striving to navigate the regulatory landscape of Georgia's insurance sector successfully. With specifics around examination scheduling, licensure prerequisites, and detailed instructions for various categories of licensure, the GID-103-AL form stands as a pivotal document for both aspiring insurance professionals and the entities that will sponsor them.

QuestionAnswer
Form NameGid 103 Al Form
Form Length2 pages
Fillable?Yes
Fillable fields88
Avg. time to fill out18 min 10 sec
Other names GID-103-AL

Form Preview Example

OFFICE OF COMMISSIONER OF INSURANCE

www.oci.ga.gov

COMMISSIONER OFINSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER

Jim Beck, Commissioner

Phone: 855-235-5174 ◊ E-mail: GAInslicensing@psionline.com

RESIDENT INSURANCE LICENSE APPLICATION

AGENTS LICENSING

GID-103-AL JAN2019

 

 

 

ONLINE APPLICATION SERVICES

LICENSURE INFORMATION

 

SCHEDULING AN EXAMINATION

 

 

 

 

 

 

 

 

 

www.sircon.com/georgia

www.oci.ga.gov

 

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

 

 

 

 

LIMITED SUBAGENT **

 

LIFE, ACCIDENT & SICKNESS

PROPERTY AND CASUALTY

 

 

ADJUSTER

 

 

 

 

PUBLIC ADJUSTER

 

ACCIDENT & SICKNESS

TITLE

 

 

 

COUNSELOR

 

 

 

 

SURPLUS LINES BROKER

 

CASUALTY

TRAVEL ACCIDENT & SICKNESS

 

 

CROP HAIL ADJUSTER

WORKERS

 

CREDIT

TRAVEL TICKET

 

 

 

FRATERNAL AGENT

 

 

 

COMPENSATION ADJUSTER

 

LIFE

VARIABLE PRODUCTS

 

 

LIMITED HEALTH COUNSELOR

 

 

 

LTD. COUNSELOR-HEALTH

WORKERS COMPENSATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL LINES

(FOR ADJUSTER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY

 

 

 

 

 

 

 

 

* FOR A

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SPONSORING INSURANCE COMPANY

 

 

 

 

 

 

 

NAIC COMPANY CODE

 

TEMPORARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE:

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SUPERVISING AGENT

 

 

 

 

 

 

 

LICENSE NUMBER

 

 

** FOR A

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIMITED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBAGENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SPONSORING AGENT

 

 

 

 

 

 

 

LICENSE NUMBER

 

 

LICENSE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT’S INFORMATION:

4.

5.

8.

9.

10.

11.

12.

FULL LEGAL NAME:

 

 

 

(FIRST)

(MIDDLE)

 

(LAST)

 

 

 

 

(SUFFIX)

SOCIAL SECURITY NUMBER:

 

 

 

 

 

 

6.

DATE OF BIRTH:

 

 

 

7.

SEX:

 

RESIDENCE ADDRESS (PHYSICAL LOCATION):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(STREET AND NUMBER REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(CITY)

(STATE)

(ZIP)

(COUNTY)

(HOME TELEPHONE)

RESIDENCE MAILING ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IF OTHER THAN 8)

 

 

 

(INCLUDE P.O.BOX, STREET, CITY, STATE, ZIP CODE AND COUNTY)

 

 

 

 

 

BUSINESS ADDRESS (PHYSICAL LOCATION):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(BUSINESS NAME)

(STREET NUMBER, STREET NAME, SUITE NUMBER)

 

 

 

 

 

 

 

 

(CITY)

 

(STATE)

(ZIP)

(COUNTY)

(BUSINESS TELEPHONE)

BUSINESS MAILING ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

(IF OTHER THAN 10)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(INCLUDE BUSINESS NAME, P.O.BOX, STREET, CITY, STATE, ZIP CODE AND COUNTY)

 

 

 

 

 

 

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?

YES

 

If yes, attach a letter from the insurer/agent to whom you are indebted giving full details.

NO

14.

Have you ever been convicted of or are you currently charged with a felony?

YES

 

If yes, attach certified copies of ALL plea agreements and court orders.

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

YES

 

have you received first offender treatment or had adjudication of guilt withheld in a criminal proceeding, other than a minor traffic offense?

NO

 

If yes, attach a supplement giving full details and attach certified copies of plea agreements and all court orders.

 

16.

Have you ever been refused or had suspended or revoked an insurance license in any state?

YES

 

If yes, attach supplement giving full details and attach certified copies of all orders.

NO

17.

Have you ever had any other administrative action instituted against you by the insurance regulatory authority of any state?

YES

 

If yes, attach supplement giving full details and attach certified copies of all orders.

NO

 

 

 

 

18.

Have you ever:

A. Had any license, permit, authorization, registration, or privilege denied, refused, revoked, suspended, limited, withdrawn,

YES

 

 

or restricted?

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

YES

 

 

disciplinary proceeding other than that of the Insurance Commissioner.

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.

This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format.

Page 1 of 2

www.oci.ga.gov

OFFICE OF COMMISSIONER OF INSURANCE

RESIDENT INSURANCE LICENSE APPLICATION

AGENTS LICENSING

GID-103-AL JAN2019

19.

Have you ever withdrawn an application for any business or professional license granted by any licensing authority?

YES

 

If yes, attach supplement indicating the type of license, reason for withdrawal and the licensing authority.

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?

YES

 

If yes, list license type, number and last year licensed. ___________________________________________

NO

 

 

 

22.

Have you held an insurance license of any type in any other state within the last 5 years?

YES

 

If yes, attach an original clearance letter from prior state dated within 90 days.

NO

 

 

 

23.

Have you completed and attached the notarized Citizenship Affidavit Form GID-276-EN to this application?

YES

 

If not, you must do so in order for this application to be processed. The form is available at www.oci.ga.gov.

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

Sworn to and Subscribed before Me this _______ day of _________________, ________.

 

SEAL

In the County of __________________________, State of _________________________.

( Seal )

&

 

 

 

 

 

SIGNATUREREQUIRED

________________________________________

___________________________

 

 

(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

 

 

 

 

 

name of sponsoring agent for limited subagent

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of company official for temporary license or

Signature

 

 

 

sponsoring agent for limited subagent license

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

All New Applicants, excluding active licensees and individuals that apply for reinstatement within 6 months of expiration date, shall

 

FINGERPRINTS

 

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

 

 

$115 ($100 LICENSE, $15 APPLICATION) THE AGENT LICENSE FEE IS

 

(FOR ONE CLASS/MAJOR LINE OF INSURANCE)

 

 

 

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

This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format.

Page 2 of 2

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Type in the necessary material in each part to fill out the PDF Gid 103 Al Form

Gid 103 Al Form blanks to fill in

Complete the RESIDENCE, ADDRESS, PHYSICAL, LOCATION STREET, AND, NUMBER, REQUIRED CITY, STATE, ZIP, COUNTY, HOME, TELEPHONE RESIDENCE, MAILING, ADDRESS, IF, OTHER, THAN BUSINESS, ADDRESS, PHYSICAL, LOCATION CITY, BUSINESS, MAILING, ADDRESS, IF, OTHER, THAN FAX, NUMBER BUSINESS, NAME STREET, NUMBER, STREET, NAME, SUITE, NUMBER and ZIP section with all the information asked by the system.

step 2 to finishing Gid 103 Al Form

Describe the key information in the YES, NOYES, NOYES, NOYES, NOYES, NOYES, NO and Page, of field.

stage 3 to completing Gid 103 Al Form

The APPLICANTS, ATTESTATION YES, NOYES, NOYES, NOYES, NOYES, NO SIGNATURE, OF, APPLICANT DATE, NOTARY, SEAL, SIGNATURE, REQUIRED Seal, and SPONSORS, CERTIFICATE area is the place where all parties can indicate their rights and responsibilities.

Gid 103 Al Form APPLICANTSATTESTATION, YESNOYESNOYESNOYESNOYESNO, SIGNATUREOFAPPLICANT, DATE, NOTARY, SEAL, SIGNATUREREQUIRED, Seal, and SPONSORSCERTIFICATE fields to complete

Prepare the template by reviewing all of these sections: Name, Title, Signature, INSTRUCTIONS, BOND, CITIZENSHIP, AFFIDAVIT FINGERPRINTS, VARIABLE, PRODUCTS COUNSELOR, LICENSE FOR, ONE, CLASS, MAJOR, LINE, OF, INSURANCE AGENT, LICENSE TEMPORARY, LICENSE LIMITEDSUBAGENT, LICENSE and FEE, SCHEDULE

step 5 to entering details in Gid 103 Al Form

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