LAIVS System
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Insurance Provider 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
Provider Name:   NAIC Number:    
Street Address:   City:  
State: Zip Code:    
                       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:   
Do you want to add a technical contact?
Do you want to add a compliance contact?
Web Login Information
User Name:
(Same as your Naic No)
Secret Question:   Secret Question Answer:    

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