Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 195 - Regulation 127-The Hurricane Property Insurance Claim Alternate Dispute Resolution Program
Section XIII-19527 - Appendix A
CERTIFICATE OF HAND-DELIVERY
HURRICANE MEDIATION PROGRAM
DISCLOSURE NOTICE
I hereby certify that on the ____ day of __________, 20____,
I appeared at:
(Physical address):
___________________________________
___________________________________
___________________________________ ,
and personally hand-delivered a true and complete copy of the hurricane mediation program disclosure notice to:
(Name of recipient):
_____________________________________
Delivery of this disclosure notice was made in connection with the following policy of insurance:
(Policy number):
_____________________________________
(Insured):
_____________________________________
(Printed name):
_____________________________________
(Signature):
_____________________________________
(Date signed):
_____________________________________
AUTHORITY NOTE: Promulgated in accordance with R.S. 22:2, 22:11, 22:2651, et seq., and the Administrative Procedure Act, R.S. 49:950, et seq.
