La. Admin. Code tit. 37 § XIII-19119

Current through Register Vol. 50, No. 9, September 20, 2024
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): ________________________________

La. Admin. Code tit. 37, § XIII-19119

Promulgated by the Department of Insurance, Office of the Commissioner, LR 49494 (3/1/2023).
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.