Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-58 - CERTIFICATION OF PRIVATE REVIEW AGENTS › Rule 120-2-58-.09 - Severability Provision

Current through Rules and Regulations filed through June 27, 2024
If any rule or portion of a rule in this Chapter of the Rules
				  and Regulations of the Office of Commissioner of Insurance or the applicability
				  thereof to any particular person or circumstance is held invalid by a court of
				  competent jurisdiction, the remainder of the rules or the applicability of such
				  provisions to other persons or circumstances shall not be affected
				  thereby.
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.
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.
_____________________________
Organization
_____________________________
Signature of Affiant
_____________________________
Name (typewritten)
_____________________________
Title (typewritten)
Sworn to and subscribed before me this___________day
				  of________,19___________.
_______________________________________
(Notary Public)
OFFICE OF COMMISSIONER OF INSURANCE
STATE OF GEORGIA
ATLANTA, GEORGIA
Biographical Affidavit
(Typewritten Only)
If you are an individual with a disability and wish to
				  acquire this affidavit 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. Full Name
				  and Address of Private Review Agent (Do Not Use Group Names).
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
In connection with the above-named private review agent, I
				  herewith make representations and supply information about myself as
				  herein-after set forth. (Attach addendum or separate sheet if space hereon is
				  insufficient to answer any question fully.) IF ANSWER IS "NO" or "NONE", SO
				  STATE.