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Agency Name *

Agency DBA Name *

Please note: Agency name must read the same as the Louisiana State Property & Casualty License.  If none, please enter NONE.

Agency License Number *

License Expiration Date *

Agency Address *

Agency City *

Agency Zip *

Agency State *

Mailing Address

Leave blank if same as agency address.

Mailing City

Mailing State

Mailing Zip

Agency Phone *

Agency Fax *

Agency Email *

Producer Code

(example:  8001234)

Agency Principal *

Example: Owner, Office Manager, Principal Contact

Principal Email *

Agency Administrator *

Person responsible for setting up users, deactivating users, and resetting passwords for agency staff.

Administrator Email *

Company Affiliate *

Attachments
 

 

Agency Name *

Agency DBA Name *
Please note: Agency name must read the same as the Louisiana State Property & Casualty License.  If none, please enter NONE.

Agency License Number *

License Expiration Date *

Agency Address *

Agency City *

Agency Zip *

Agency State *


Mailing Address
Leave blank if same as agency address.

Mailing City

Mailing State


Mailing Zip

Agency Phone *

Agency Fax *

Agency Email *

Producer Code

(example:  8001234)

Agency Principal *
Example: Owner, Office Manager, Principal Contact

Principal Email *

Agency Administrator *
Person responsible for setting up users, deactivating users, and resetting passwords for agency staff.

Administrator Email *

Company Affiliate *


 

After clicking submit, please email the following documents to policyadmin@lacitizens.com or fax to (504) 831-6676.

a. Completed W-9 Form
b. Agency Property and Casualty License
c. E&O Coverage Certificate

Registration will not be complete until these documents have been received.


Please note: These documents are for the Agency and do not need to be submitted for each individual producer.


©2008 LCPIC