OFFICE OF COMMISSIONER OF INSURANCE COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER Ralph T. Hudgens, Commissioner www.oci.ga.gov 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 ◊ Fax: 770-344-5798 ◊ E-mail: TBrewster@oci.ga.gov AUTHORITY FOR RELEASE OF INFORMATION LIMITED RISK ENTITIES LIMITED RISK GID-053-NT DEC2015 I, ______________________________________________________________________, presently reside at ______________________________________________________________________________________ and am affiliated with, or proposed to be affiliated with, __________________________________________ which applies for licensure or a permit to organize by the Office of Commissioner of Insurance. I understand that the Office of Insurance will conduct an investigation of my background. In that regard, I hereby waive any right of confidentiality as it reasonably relates to this inquiry. I hereby give my permission and waive any provisions of law that forbids any court, policy agency, employer, firm, or person, disclosing any knowledge or information they have concerning me which is requested by the Office of Commissioner of Insurance. I further consent and request that the supervisor of the Limited Risk Entities in the Insurance Financial Oversight Division- his/her representative be provided with the performance of their investigation. I recognize the right of the Office of Commissioner of Insurance to treat, at its discretion, certain sources as confidential, and right to withhold from my agent or me the names of such confidential sources, and information obtained therefrom. Applicant's Signature_____________________________________ Date ____________________ This document was executed and signed in the presence of the following witnesses: Witness-1 Signature _____________________________________ Date _____________________ Witness-2 Signature _____________________________________ Date _____________________ Sworn to and Subscribed before Me this _______ day of ____________, __________. NOTARY In the County of ___________________________, State of __________________. ___________________________ (Notary Public) ( Seal ) ________________________________ (My Commission Expires) This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format. American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1