La. Admin. Code tit. 37 § XIII-19527
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):
_____________________________________
La. Admin. Code tit. 37, § XIII-19527