1. 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

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.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Insurance, Office of the Commissioner, LR 49:494 (March 2023).