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

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.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Insurance, Office of the Commissioner, LR 49:902 (May 2023).