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Form Name	Gid 103 Al Form
Form Length	2 pages
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Avg. time to fill out	30 sec
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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

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:

10.

11.

12.

FULL LEGAL NAME:

(FIRST)

(MIDDLE)

(LAST)

(SUFFIX)

SOCIAL SECURITY NUMBER:

DATE OF BIRTH:

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
		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

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.

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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
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

!!!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 )
&			( 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			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)

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.

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