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

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

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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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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 Exemption Certification Form
____________________________________________________________________
(Name of the Licensee and NAIC Number)
I, the undersigned, hereby certify that the above-named licensee is exempt from the
Information Security Program (ISP) requirements of La. R.S. 22:2504 based on one or
more of the following exemptions pursuant to La. R.S. 22:2509:
(Check all that apply)
_____ Having fewer than twenty-five employees.
_____ Having less than five million dollars in gross annual revenue.
_____ Having less than ten million dollars in year-end total assets.
_____ Being subject to the Health Insurance Portability and Accountability Act, P.L.
104-191, 110 Stat. 1936, and doing all of the following:
(1) Establishing and maintaining an ISP pursuant to any statutes, rules,
regulations, procedures, or guidelines established pursuant to the Health
Insurance Portability and Accountability Act.
(2) Complying with and submitting, upon request of the Commissioner of
Insurance, a written statement certifying compliance with the ISP established
and maintained pursuant to the Health Insurance Portability and
Accountability Act.
_____ Being an employee, agent, representative, or designee of a licensee, who is also
a licensee, to the extent that the employee, agent, representative, or designee
is covered by the ISP of the other licensee.
_____ Being affiliated with a depositary institution subject to the Interagency Guidelines
Establishing Information Security Standards pursuant to the Gramm-Leach-
Bliley Act, 15 U.S.C.6801 and 6805, and doing all of the following:
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 Exemption Certification Form
____________________________________________________________________
(Name of the Licensee and NAIC Number)
I, the undersigned, hereby certify that the above-named licensee is exempt from the
Information Security Program (ISP) requirements of La. R.S. 22:2504 based on one or
more of the following exemptions pursuant to La. R.S. 22:2509:
(Check all that apply)
_____ Having fewer than twenty-five employees.
_____ Having less than five million dollars in gross annual revenue.
_____ Having less than ten million dollars in year-end total assets.
_____ Being subject to the Health Insurance Portability and Accountability Act, P.L.
104-191, 110 Stat. 1936, and doing all of the following:
(1) Establishing and maintaining an ISP pursuant to any statutes, rules,
regulations, procedures, or guidelines established pursuant to the Health
Insurance Portability and Accountability Act.
(2) Complying with and submitting, upon request of the Commissioner of
Insurance, a written statement certifying compliance with the ISP established
and maintained pursuant to the Health Insurance Portability and
Accountability Act.
_____ Being an employee, agent, representative, or designee of a licensee, who is also
a licensee, to the extent that the employee, agent, representative, or designee
is covered by the ISP of the other licensee.
_____ Being affiliated with a depositary institution subject to the Interagency Guidelines
Establishing Information Security Standards pursuant to the Gramm-Leach-
Bliley Act, 15 U.S.C.6801 and 6805, and doing all of the following:
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
(1) Establishing and maintaining an ISP pursuant to any statutes, rules,
regulations, procedures, or guidelines established pursuant to the Gramm-
Leach-Bliley Act.
(2) Complying with and submitting, upon request of the Commissioner of
Insurance, a written statement certifying compliance with the ISP established
and maintained pursuant to the Gramm-Leach-Bliley Act.
_____ Being subject to another jurisdiction approved by the Commissioner of Insurance
and doing all of the following:
(1) Establishing and maintaining an ISP pursuant to any statutes, rules,
regulations, procedures, or guidelines established by another jurisdiction.
(2) Complying with and submitting this written statement certifying its compliance
with the ISP established and maintained pursuant to the guidelines
established by another jurisdiction, to wit: ___________________________.
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
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