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Division of Life and Annuities And Long Term Care

Insurance Company Contact Request Form - Manual Submission

To manually submit the Insurance Company Contact Request Form follow the steps below:

Step 1:

Download Insurance Company Contact Request Form, fill in all fields and print from your computer.  If you do not have capability to download and/or print the form, please contact:

Sam Brooks, Assistant Director
(225) 342-1253
sbrooks@ldi.la.gov

Step 2:

Please mail the completed form and a scanned copy of the Death Certificate to:

Louisiana Department of Insurance
Divsion of Life and Annuities
1702 N. 3rd Street
Baton Rouge, LA 70802