LAIVS
 

Insurance Company Registration Form

Please fill out this form only if your company is licensed to provide automobile liability insurance in the State of Louisiana.

General Information
Insurance Company Name: NAIC Number:
Street Address: City:
State: Zip Code:
 
Louisiana Policies
                     Does your company currently write automobile insurance in LA?
            Does your company issue ONLY commercial automobile policies in LA?
                                Does your company cover less than 500 vehicles in LA? 
Main/Functional Contact Details
First Name: Last Name:
Middle Initial: Phone Number:
Fax Number: Email Address:
Technical Contact Details
First Name: Last Name:
Middle Initial: Phone Number:
Fax Number: Email Address:
 
Compliance contact Details
First Name: Last Name:
Middle Initial: Phone Number:
Fax Number: Email Address:
 
Web Login Information
User Name:
(Same as your Naic No)
 Password:
Secret Question: Answer to Secret Question:
 

 
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