LAIVS


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? YesNo
* Does your company issue ONLY commercial automobile policies in LA? YesNo
* Does your company cover less than 500 vehicles in LA? YesNo

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)	Password:	* *
Secret Question:	*	Secret Question Answer:	* *