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Documents
45
![Form COR-1 "Change of Record Form (Change of Name/Trade Name)" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809313/form-cor-1-change-record-form-change-name-trade-name-louisiana.png "Form COR-1 "Change of Record Form (Change of Name/Trade Name)" - Louisiana")
![Form CR-1 "Certificate of Certified Reinsurer" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18092/1809284/form-cr-1-certificate-certified-reinsurer-louisiana.png "Form CR-1 "Certificate of Certified Reinsurer" - Louisiana")
![Form PEO1 "Registration to Act as a Professional Employer Organization in the State of Louisiana" - Louisiana](https://data.templateroller.com/pdf_docs_html/1799/17995/1799596/form-peo-1-registration-to-act-as-a-professional-employer-organization-in-the-state-louisiana-louisiana.png "Form PEO1 "Registration to Act as a Professional Employer Organization in the State of Louisiana" - Louisiana")
![Form 1071 "Quarterly Tax Statement" - Louisiana, 2020](https://data.templateroller.com/pdf_docs_html/2064/20646/2064678/form-1071-quarterly-tax-statement-louisiana.png "Form 1071 "Quarterly Tax Statement" - Louisiana, 2020")
![Form 203P "Acceptance of Access to Records Request" - Louisiana](https://data.templateroller.com/pdf_docs_html/1812/18122/1812243/form-203p-acceptance-access-to-records-request-louisiana.png "Form 203P "Acceptance of Access to Records Request" - Louisiana")
![Form 1623 "Application for Resident or Non-resident Managing General Agent" - Louisiana](https://data.templateroller.com/pdf_docs_html/1799/17995/1799594/form-1623-application-for-resident-or-non-resident-managing-general-agent-louisiana.png "Form 1623 "Application for Resident or Non-resident Managing General Agent" - Louisiana")
![Form 1068E "Capco Credit Notification of Sale or Transfer" - Louisiana, 2018](https://data.templateroller.com/pdf_docs_html/1809/18093/1809329/form-1068e-2018-capco-credit-notification-sale-or-transfer-louisiana.png "Form 1068E "Capco Credit Notification of Sale or Transfer" - Louisiana, 2018")
![Form 1265 B "Surplus Line Producer's Quarterly Tax Statement Self-procurement" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809379/form-1265-b-surplus-line-producer-s-quarterly-tax-statement-self-procurement-louisiana.png "Form 1265 B "Surplus Line Producer's Quarterly Tax Statement Self-procurement" - Louisiana")
![Form 1566 ENTITY "Application for Entity Navigator License" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809339/form-1566-entity-application-entity-navigator-license-louisiana.png "Form 1566 ENTITY "Application for Entity Navigator License" - Louisiana")
!["Application to Act as a Discount Medical Plan" - Louisiana](https://data.templateroller.com/pdf_docs_html/2064/20646/2064671/application-to-act-as-a-discount-medical-plan-louisiana.png ""Application to Act as a Discount Medical Plan" - Louisiana")
!["Application for Dissolution of a Louisiana Domiciled Insurer" - Louisiana](https://data.templateroller.com/pdf_docs_html/2064/20646/2064670/application-for-dissolution-of-a-louisiana-domiciled-insurer-louisiana.png ""Application for Dissolution of a Louisiana Domiciled Insurer" - Louisiana")
!["Application to Act as a Third Party Administrator in the State of Louisiana" - Louisiana](https://data.templateroller.com/pdf_docs_html/2064/20646/2064672/application-to-act-as-a-third-party-administrator-in-the-state-of-louisiana-louisiana.png ""Application to Act as a Third Party Administrator in the State of Louisiana" - Louisiana")
!["Director's Acceptance of Trust" - Louisiana](https://data.templateroller.com/pdf_docs_html/2064/20646/2064676/director-s-acceptance-of-trust-louisiana.png ""Director's Acceptance of Trust" - Louisiana")
!["Application for Change of Control of a Louisiana Domiciled Insurer" - Louisiana](https://data.templateroller.com/pdf_docs_html/2064/20646/2064673/application-for-change-of-control-of-a-louisiana-domiciled-insurer-louisiana.png ""Application for Change of Control of a Louisiana Domiciled Insurer" - Louisiana")
!["Application for Registration to Actas a Professional Employer Organization in the State of Louisiana" - Louisiana](https://data.templateroller.com/pdf_docs_html/2064/20646/2064674/application-for-registration-to-actas-a-professional-employer-organization-in-the-state-of-louisiana-louisiana.png ""Application for Registration to Actas a Professional Employer Organization in the State of Louisiana" - Louisiana")
!["Application for Health Maintenance Organization License in Louisiana" - Louisiana](https://data.templateroller.com/pdf_docs_html/2026/20268/2026834/application-for-health-maintenance-organization-license-in-louisiana-louisiana.png ""Application for Health Maintenance Organization License in Louisiana" - Louisiana")
!["Application for a Certificate of Authority as a Louisiana Domiciled Insurer" - Louisiana](https://data.templateroller.com/pdf_docs_html/2064/20646/2064682/application-for-a-certificate-of-authority-as-a-louisiana-domiciled-insurer-louisiana.png ""Application for a Certificate of Authority as a Louisiana Domiciled Insurer" - Louisiana")
!["Application to Act as a Independent Review Organization in the State of Louisiana" - Louisiana](https://data.templateroller.com/pdf_docs_html/2026/20268/2026833/application-to-act-as-a-independent-review-organization-in-the-state-of-louisiana-louisiana.png ""Application to Act as a Independent Review Organization in the State of Louisiana" - Louisiana")
!["Acknowledgement of Applicant for Personal Lines and Health and Accident Insurance Coverage in the Surplus Lines Market" - Louisiana](https://data.templateroller.com/pdf_docs_html/2026/20268/2026836/acknowledgement-of-applicant-for-personal-lines-and-health-and-accident-insurance-coverage-in-the-surplus-lines-market-louisiana.png ""Acknowledgement of Applicant for Personal Lines and Health and Accident Insurance Coverage in the Surplus Lines Market" - Louisiana")
!["Self-storage Limited License Application Addendum Insurer Certification Form" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809363/self-storage-limited-license-application-addendum-insurer-certification-form-louisiana.png ""Self-storage Limited License Application Addendum Insurer Certification Form" - Louisiana")
!["State to State Transfer Form" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18092/1809280/state-to-state-transfer-form-louisiana.png ""State to State Transfer Form" - Louisiana")
!["License Surrender and Letter of Clearance" - Louisiana](https://data.templateroller.com/pdf_docs_html/566/5662/566298/license-surrender-and-letter-of-clearance-louisiana.png ""License Surrender and Letter of Clearance" - Louisiana")
!["Application for a Certificate of Authority as a Louisiana Domiciled Insurer Form" - Louisiana](https://data.templateroller.com/pdf_docs_html/1817/18170/1817038/application-a-certificate-authority-as-a-louisiana-domiciled-insurer-form-louisiana.png ""Application for a Certificate of Authority as a Louisiana Domiciled Insurer Form" - Louisiana")
![Exhibit E "Rating Examples - Homeowners" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809308/exhibit-e-rating-examples-homeowners-louisiana.png "Exhibit E "Rating Examples - Homeowners" - Louisiana")
!["Application to Register as a Non-navigator" - Louisiana](https://data.templateroller.com/pdf_docs_html/1817/18170/1817034/application-to-register-as-a-non-navigator-louisiana.png ""Application to Register as a Non-navigator" - Louisiana")
!["Application to Act as a Certified Reinsurer for Louisiana Domiciled Insurers" - Louisiana](https://data.templateroller.com/pdf_docs_html/1799/17995/1799590/application-to-act-as-a-certified-reinsurer-for-louisiana-domiciled-insurers-louisiana.png ""Application to Act as a Certified Reinsurer for Louisiana Domiciled Insurers" - Louisiana")
!["Louisiana Standardized Credentialing Application Form" - Louisiana](https://data.templateroller.com/pdf_docs_html/1799/17998/1799899/louisiana-standardized-credentialing-application-form-louisiana.png ""Louisiana Standardized Credentialing Application Form" - Louisiana")
!["Agreement to Comply With Rates, Rules and Regulations" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809334/agreement-to-comply-with-rates-rules-and-regulations-louisiana.png ""Agreement to Comply With Rates, Rules and Regulations" - Louisiana")
!["Ucaa Statement of Withdrawal Louisiana Specific Addendum Form" - Louisiana](https://data.templateroller.com/pdf_docs_html/1812/18122/1812251/ucaa-statement-withdrawal-louisiana-specific-addendum-form-louisiana.png ""Ucaa Statement of Withdrawal Louisiana Specific Addendum Form" - Louisiana")
!["Oath of Officer" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18092/1809289/oath-officer-louisiana.png ""Oath of Officer" - Louisiana")
!["Affidavit of Publication of Public Notice" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18092/1809283/affidavit-publication-public-notice-louisiana.png ""Affidavit of Publication of Public Notice" - Louisiana")
!["Application Verifying Eligibility as Surplus Lines Insurer in the State of Louisiana" - Louisiana](https://data.templateroller.com/pdf_docs_html/1799/17996/1799600/application-verifying-eligibility-as-surplus-lines-insurer-in-the-state-of-louisiana-louisiana.png ""Application Verifying Eligibility as Surplus Lines Insurer in the State of Louisiana" - Louisiana")
![Exhibit I "Louisiana Rate Revision Questionnaire by Territory" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809305/exhibit-i-louisiana-rate-revision-questionnaire-by-territory-louisiana.png "Exhibit I "Louisiana Rate Revision Questionnaire by Territory" - Louisiana")
!["Surety Bond" - Louisiana](https://data.templateroller.com/pdf_docs_html/1799/17995/1799597/surety-bond-louisiana.png ""Surety Bond" - Louisiana")
![Exhibit D "Private Passenger Automobile Rating Examples" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18092/1809298/exhibit-d-private-passenger-automobile-rating-examples-louisiana.png "Exhibit D "Private Passenger Automobile Rating Examples" - Louisiana")
![Exhibit A.1 "Experience Underlying Rate Revision Filing" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18092/1809293/exhibit-a-1-experience-underlying-rate-revision-filing-louisiana.png "Exhibit A.1 "Experience Underlying Rate Revision Filing" - Louisiana")
!["Application to Act as a Captive Insurer in the State of Louisiana" - Louisiana](https://data.templateroller.com/pdf_docs_html/1799/17995/1799589/application-to-act-as-a-captive-insurer-in-the-state-of-louisiana-louisiana.png ""Application to Act as a Captive Insurer in the State of Louisiana" - Louisiana")
"Application to Act as a Captive Insurer in the State of Louisiana" - Louisiana
Size: 247 KB
16 pages
![Exhibit F "Louisiana Operating Results" - Louisiana](https://data.templateroller.com/pdf_docs_html/1809/18093/1809300/exhibit-f-louisiana-operating-results-louisiana.png "Exhibit F "Louisiana Operating Results" - Louisiana")
