LAC 37:XIII.19119. Appendix A—Certificate Of Hand-Delivery

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): __________________________________