LAC 37:XIII.19527. Appendix A

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): _____________________________________