LAC 37:XIII.9519. Louisiana Application for Military Discount―Appendix

LOUISIANA APPLICATION FOR MILITARY DISCOUNT ____________________________ ______________________________ Name of Insurance Company Policy No. or Application No. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. If you have any questions about this “Louisiana Application For Military Discount” form ask your agent for an explanation or contact the Louisiana Department of Insurance at (800) 259-5300 or (225) 342-5900. You must complete all sections on this form. If the spouse or dependent sections are not applicable, you must check the N/A box next to the associated fields. _____________________________________ __________________ Full Name of Active Military Personnel Date _______________________________ __________________________ Date of Birth Home Phone ____________________________________________________________ Home Address __________________________  N/A __________________  N/A Name of Spouse Spouse Date of Birth (if not applicable, check N/A) (if not applicable, check N/A) ______________________________________________________  N/A Full Name and Date of Birth of Licensed Dependents (if not applicable, check N/A)  Copy of Permanent Change of Station (PCS) Orders attached OR  Permanent Change of Station (PCS) Orders previously submitted The undersigned hereby certifies that he/she is on active duty and permanently based in Louisiana and qualifies as "active military personnel" (AMP) as defined by LSA-R.S. 22:1482 and Regulation 81, and is eligible for the military discount set forth in LSA-R.S. 22:1482 for personal automobile liability insurance policy. The AMP further certifies that the information provided in this "Louisiana Application For Military Discount" form is true and correct and that he/she will promptly notify his/her automobile insurer of any change in the above information. The AMP acknowledges that any false, fraudulent or misleading statement may subject him/her to civil and criminal penalties, including those penalties set forth in LSA-R.S. 22:1924, and any applicable provisions of Title 14, the Louisiana Criminal Code. ______________________________ _____________________________ Signature of Active Military Print Name of Active Military Personnel (AMP) Personnel (AMP)