La. Admin. Code tit. 37 § XIII-19119
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