Office of Insurance and Safety Fire CommissionerRalph T. Hudgens
Commissioner
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Surplus Lines Brokers Forms

ATTENTION: TO ALL NEW APPLICANTS - EFFECTIVE 1/1/2012. 
In accordance with state law, beginning January 1, 2012, the Office of Insurance and Safety Fire Commissioner will be changing its procedures regarding the verification of lawful presence of persons applying for all licenses, permits, registrations and certificates. Please click HERE for more information.

ATTENTION:
 We have NEW IMPORTANT payment procedures. Please view them HERE.

Form #: ASI 6011-08 This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2011
Title: Request for Name and Address Change
Request for Name and Address Change for Producer and Agency

Form #: GID-006-AL This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2011
Title: Request for Clearance Letter (same as GID-AL-6)
Request for Clearance Letter

Form #: GID-101B-AL This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2014
Title: Individual License Renewal Application
This form is used for renewal by Georgia resident and non-resident agent licensees. If you are a non-citizen / alien of the USA, you must include the GID-276-EN Citizen Affidavit Form with this renewal.

Form #: GID-101B-AL This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2014
Title: Individual License Renewal Application
This form is used for renewal by Georgia resident and non-resident agent licensees. If you are a non-citizen / alien of the USA, you must include the GID-276-EN Citizen Affidavit Form with this renewal.

Form #: GID-103-AL MARCH 2013 This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2013
Title: Resident Insurance License Application
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-114-AL This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2011
Title: Surplus Lines Broker
This form requires a seal to be affixed to the document. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-276-EN This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2013
Title: Citizenship Affidavit
Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: UANRIPL This is in the Adobe Portable Document format (pdf)\nDivision: Agents LicensingPublished: 2012
Title: Uniform Application for Non-Resident Individual Producer License
Includes instructions, application form and Citizenship Affidavit. Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

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