"Louisiana Insurance Data Security Law Information Security Program Certification Form" - Louisiana

Louisiana Insurance Data Security Law Information Security Program Certification Form is a legal document that was released by the Louisiana Department of Insurance - a government authority operating within Louisiana.

Form Details:

  • The latest edition currently provided by the Louisiana Department of Insurance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Louisiana Department of Insurance.

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L
D
I
O U I S I A N A
E P A R T M E N T O F
N S U R A N C E
J A M E S J . D O N E L O N
C O M M I S S I O N E R
Louisiana Insurance Data Security Law
Information Security Program Certification Form
____________________________________________________________________
(Name of the Licensee and NAIC Number)
I, the undersigned, hereby certify that the above-named licensee is duly organized under
the laws of the State of Louisiana and complies with the Information Security Program
requirements of La. R.S. 22:2504.
I certify, to the best of my knowledge, that the information submitted on this form is true
and correct. By submitting this form, I am acknowledging that I am duly authorized to
submit this form on behalf of the licensee.
____________________________________________________________________
Signature/Date
____________________________________________________________________
Printed Name/Title
____________________________________________________________________
Contact Email/Phone Number
P. O. B
94214 • B
R
, L
70804-9214
OX
ATON
OUGE
OUISIANA
P
(225) 342-5900 • F
(225) 342-3078
HONE
AX
https://www.ldi.la.gov
L
D
I
O U I S I A N A
E P A R T M E N T O F
N S U R A N C E
J A M E S J . D O N E L O N
C O M M I S S I O N E R
Louisiana Insurance Data Security Law
Information Security Program Certification Form
____________________________________________________________________
(Name of the Licensee and NAIC Number)
I, the undersigned, hereby certify that the above-named licensee is duly organized under
the laws of the State of Louisiana and complies with the Information Security Program
requirements of La. R.S. 22:2504.
I certify, to the best of my knowledge, that the information submitted on this form is true
and correct. By submitting this form, I am acknowledging that I am duly authorized to
submit this form on behalf of the licensee.
____________________________________________________________________
Signature/Date
____________________________________________________________________
Printed Name/Title
____________________________________________________________________
Contact Email/Phone Number
P. O. B
94214 • B
R
, L
70804-9214
OX
ATON
OUGE
OUISIANA
P
(225) 342-5900 • F
(225) 342-3078
HONE
AX
https://www.ldi.la.gov