Form Gid 57 – Fill Out and Use This PDF

Form GID-57

Page 1 of 3

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) 656-2056 / TDD (404) 656-4031

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.

Form GID-57

Page 2 of 3

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 GID-65(UR) for each of the persons listed in item 3.

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 120-2-58-.03(6).

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. §§ 33-46-4, 33-46-5 and Chapter 39 of Title 33 of the Official Code of Georgia Annotated; that all the foregoing information and documentary evidence submitted is true, complete, and correct to the best of my knowledge and belief. I understand that my certification is subject to administrative action if false information is contained herein.

Form GID-57

Page 3 of 3

_______________________________________________

Organization

_______________________________________________

Signature of Affiant

_______________________________________________

Name (typewritten)

_______________________________________________

Title (typewritten)

Sworn to and subscribed before me

this day of ______, 20 .

_________________________________

(Notary Public)