Georgia Insurance Form GID-276-EN is the citizenship affidavit the Office of Commissioner of Insurance and Safety Fire requires with every insurance licensing application. It exists to verify lawful presence under O.C.G.A. §50-36-1, and the Department will not process your application without it. You fill it out, get it notarized, and submit it alongside a copy of a secure and verifiable ID as part of your licensing package.
Who Has to File It
Every new applicant subject to the Department’s licensing authority must submit GID-276-EN, regardless of citizenship status. The requirement comes from Georgia’s Illegal Immigration Reform and Enforcement Act of 2011. Non-citizen applicants also have to resubmit the form at each renewal; U.S. citizens generally do not refile at renewal.
The affidavit covers three regulated categories: insurance (agents, agencies, and carriers), safety fire businesses, and industrial loan licensees.
If the applicant is a business entity rather than an individual, an employee or officer with authority over the application must personally sign the affidavit. When that authorized person changes, the new individual has to file a fresh GID-276-EN with the next application, even if the prior signer already filed one.
Filling Out the Form
You can download the form from the Georgia Department of Insurance site at oci.ga.gov. It is short but must be notarized, so line up a notary before you sign.
Business Information
Select which of the three business types the affidavit covers: Insurance, Safety Fire, or Industrial Loan. If you pick Insurance, specify whether you are an agent, an agency, or a carrier. Write the business name on the line matching your selection. Enter your License number, NAIC number, or Employer ID number if you already have one. New applicants without any of those identifiers should note that on the form.
Citizenship Status
Check exactly one of the three boxes:
- United States citizen, by birth or naturalization.
- Legal permanent resident. Provide your alien number.
- Qualified alien or non-immigrant under the Federal Immigration and Nationality Act. Provide your alien number.
If you check either non-citizen box and leave the alien registration number blank, the Department cannot verify lawful presence and will return the application.
Notarization
The form is a sworn affidavit and has to be signed in front of a notary public. Fill in the city and state of notarization, sign, and print your name. The notary adds their seal, signature, and commission expiration date. An unnotarized form will not be accepted.
The Identification Document You Attach
Along with the notarized affidavit, submit a legible copy of the front and back of one secure and verifiable identification document. Both sides are required, and blurry or cut-off copies delay processing. Send copies, not originals; the Department does not return submitted documents.
The Department publishes the list of documents that qualify as secure and verifiable under Georgia law. Common examples include a valid U.S. passport, a state-issued driver’s license, and a permanent resident card. Check the current list on the Citizenship Affidavit page at oci.georgia.gov before you submit, since acceptable documents can change with updates to state or federal law.
Submitting It With Your Application
GID-276-EN is not a standalone filing. The notarized affidavit and the ID copy travel with the rest of your licensing application materials, and the Department will not move your application forward until all of it arrives. The current submission address and any electronic filing options are on the Citizenship Affidavit instructions page at oci.georgia.gov. If you are mailing physical documents, use a tracked delivery method so you can confirm receipt of your ID copies.
Penalties for a False Statement
Because it is a sworn affidavit, knowingly submitting false, fictitious, or fraudulent information on GID-276-EN is a violation of O.C.G.A. §16-10-20, Georgia’s statute on false statements and writings. A false affidavit also puts at risk any license issued on the basis of the application.
If You Are Actually Trying to File a Complaint
GID-276-EN is sometimes confused with the consumer complaint process, but they are unrelated. Disputes with an insurance company, agent, or adjuster go through the Department’s Consumer Services Division, not through this affidavit form.