Question	Answer
Form Name	Gid 103 Al Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	88
Avg. time to fill out	18 min 10 sec
Other names	GID-103-AL

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A. Had any license, permit, authorization, registration, or privilege denied, refused, revoked, suspended, limited, withdrawn,	YES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
		B. Had any other disciplinary action taken against you?	NO
			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
			NO

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	Have you ever withdrawn an application for any business or professional license granted by any licensing authority?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
20.		NO
		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

NOTARY	Sworn to and Subscribed before Me this _______ day of _________________, ________.
SEAL	In the County of __________________________, State of _________________________.		( Seal )
&			( Seal )
&
SIGNATUREREQUIRED	________________________________________	___________________________
	(Signature Of Notary Public)	(My Commission Expires)

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			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
BOND		appropriate BOND with this application.
		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
COUNSELOR LICENSE		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
	LIMITED SUBAGENT LICENSE					OF AUTHORITY)
						OF AUTHORITY)

ADJUSTER, COUNSELOR & LIMITED GROUP HEALTH COUNSELOR LICENSES					$115 ($100 LICENSE, $15 APPLICATION)
SURPLUS LINES BROKER LICENSE					$615 ($600 LICENSE, $15 APPLICATION)

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