As an integral part of maintaining transparency and compliance within the state of Georgia, the GID-57 form presents a structured platform for organizations seeking certification as Private Review Agents. This form, meticulously crafted under the stewardship of the Office of the Commissioner of Insurance, John W. Oxendine, signifies a critical step towards ensuring that entities operate in line with the stringent requirements laid down by Georgia's legislation. To navigate the application process, organizations are mandated to furnish extensive information ranging from basic identification details to comprehensive documentation that outlines the organizational structure, regulatory compliance, and operational integrity. This includes the provision of original or certified copies of foundational documents such as partnership agreements, articles of incorporation, and other pertinent legal instruments alongside internal governing documents like bylaws. Additionally, the form delves into the personnel aspect by requiring biographical affidavits for key individuals responsible for the entity's operations within the state. In highlighting the procedural facets, the application process is differentiated based on the nature of the applicant – be it a sole proprietorship, partnership, or corporation – with each category subjected to specific attestation requirements aimed at reinforcing the authenticity and accuracy of the information provided. The solemn affirmation at the form's conclusion anchors the application in a legal and ethical commitment to uprightness, underscoring the importance of truthfulness in the pursuit of certification. This procedural rigor emphasizes not only the potential of the GID-57 form as a gatekeeping instrument for the insurance sector in Georgia but also as a reflection of the broader commitment to regulatory compliance, operational transparency, and the safeguarding of public interest within the state's economic and legal frameworks.
| Question | Answer |
|---|---|
| Form Name | Form Gid 57 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | TDD, ga gid 65 ur, ADA, gid 57 form |
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JOHN W. OXENDINE
OFFICE OF COMMISSIONER OF INSURANCE
STATE OF GEORGIA
ATLANTA, GEORGIA
APPLICATION FOR CERTIFICATION AS A PRIVATE REVIEW AGENT
(Typewritten Only)
If you are an individual with a disability and wish to acquire this application in an alternative format, please contact the ADA Coordinator at the Georgia Insurance Department, 2 Martin Luther King Jr. Drive, Atlanta, Georgia 30334 (404)
Application is hereby made for certification to operate as a Private Review Agent pursuant to the Laws of Georgia. In support thereof, the following information and documentary evidence is submitted:
Date of |
filing: |
___________________________________________________ |
Name of |
organization: ______________________________________________ |
|
Mailing |
address: ___________________________________________________ |
|
Street |
address: |
___________________________________________________ |
Office |
building: |
__________________ Room number: __________________ |
City: |
_________ |
County: __________ State: _______ Zip: _________ |
Telephone number: (___) ____________ Fax number:(___) ______________
Name of Attorney or Principal filing this application:
____________________________________________________________________
Mailing address: __________________________________________________
Street address: ____________________________________________________
City: _____________ State: ________________ Zip: _________________
Telephone number: (___) __________ |
Fax number: (___) ____________ |
NOTE: ANSWER THE FOLLOWING QUESTIONS AND PROVIDE THE INFORMATION REQUESTED ON SEPARATE SHEETS IDENTIFYING EACH BY THE CORRESPONDING NUMBER ON THIS APPLICATION.
1. Submit all applicable organizational documents including an organizational chart. The following documents MUST BE an original copy or a certified copy of the original: partnership agreement; articles of incorporation certified by your Secretary of State; trade name certificate; trust agreement; any other applicable documents; and all amendments to those documents.
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2.Provide one copy of the bylaws, rules and regulations or similar documents regulating the affairs of the private review agent certified by the principal partners or the president and secretary and containing the corporate seal.
3.List the names, addresses, and official titles of positions held by individuals who are responsible for the conduct of the affairs of the private review agent in Georgia.
4.Submit one copy of the Biographical Affidavit on Form
5.Indicate if the private review agent plans to utilize a fictitious or "dba" name. If so, attach a certified copy of the recorded application received from the Clerk of the Superior Court in the county where doing business.
6.Submit all other items required under Rule
DIRECTIONS FOR ATTESTING TO THIS APPLICATION:
a.If applicant is a sole proprietor, the application must be sworn by the sole proprietor.
b.If applicant is a partnership, the application must be sworn by the principal partners or by all officers and directors.
c.If applicant is a corporation, the application must be sworn by the president and secretary.
========================================================================
THE FOLLOWING ATTESTATION FORM SHALL BE USED:
I do solemnly swear or affirm that I am familiar with the Laws of Georgia relating to Private Review Agents; that I have complied with all of the requirements of O.C.G.A. §§
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_______________________________________________
Organization
_______________________________________________
Signature of Affiant
_______________________________________________
Name (typewritten)
_______________________________________________
Title (typewritten)
Sworn to and subscribed before me
this day of ______, 20 .
_________________________________
(Notary Public)