Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 191 - Regulation 124-Catastrophe Claims Process Disclosure Form-Guide
Section XIII-19119 - Appendix A-Certificate Of Hand-Delivery
CATASTROPHE CLAIMS PROCESS DISCLOSURE FORM-GUIDE
I hereby certify, under penalty of perjury, that on the _____ day of _____________, 20____, I appeared at:
(Physical address): _____________________________
_____________________________________________
_____________________________________________,
and personally hand-delivered a true and complete copy of the Catastrophe Claims Process Disclosure Form-Guide to:
(Name of recipient): _____________________________
Delivery of this disclosure form-guide was made in connection with the following policy of insurance:
(Policy number): ______________________________
(Policyholder): ______________________________
(Printed Name): ______________________________
(Signature): __________________________________
(Date signed): ________________________________
AUTHORITY NOTE: Promulgated in accordance with R.S. 22:2, 22:11, 22:1897, and the Administrative Procedure Act, R.S. 49:950, et seq.