Report of 2016 Premiums for use in determining members participation for the 2017 Association Year

The forms for reporting 2016 premiums written in Georgia for use in determining your company’s participation in the 2016 Association Year’s operating results of the Georgia FAIR plan are attached.

It should be noted that the Georgia FAIR plan is a mandatory FAIR plan established by Georgia Laws and participation is required for every insurer authorized to write Property insurance in the state.

The following should be submitted no later than April 1, 2017.

  • use whole $ only
  • A group report is preferred over individual reports
  • Group reports must file individual company support documents.

If your Company has moved, merged with another company, changed names or had any other significant change within the past 24 months, please submit a current W-9.  In order for your application to be complete, you must submit the following:

  • JURAT PAGE
  •  STATUTORY PAGE 14

Please email these pages to premiumcall@georgiaunderwriting.com .

Signatory

Name
Title
Phone
Email

Commercial and Personal Lines

D1 - Personal Lines (Total)
D2 - Commercial Lines (Total)
Total Adjusted Written Premiums

Reporting Type

Reporting Entity CompanyGroup

Company or Group Name:

If company:
Company FEIN
Company NAIC

If Group, list the included companies:

# Company Name FEIN NAIC
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
# Company Name FEIN NAIC
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

If any name changes or mergers have occurred during the past 24 months, please list with the effective date.

Your filing requirements are not fulfilled until we have received a copy of your (Page 1 – premiums breakdown, Statutory Pg.14 and Jurat page to: premiumcall@georgiaunderwriting.com

-Georgia Underwriters Association