Get Louisiana Notice Of Election/revocation Of Coverage - Summit

This guide provides clear instructions on how to complete the Louisiana Notice Of Election/revocation Of Coverage - Summit form online. By following these steps, users can ensure their submissions are accurate and efficient.

Follow the steps to complete your form successfully.

1. Press the ‘Get Form’ button to access the Louisiana Notice Of Election/revocation Of Coverage - Summit form and open it in your chosen document editor.
2. Fill in the company name and the Federal Employee Identification Number (FEIN) in the designated fields. Make sure to verify that the information is correct to avoid any delays.
3. Provide the company address, including the city, state, and ZIP code in the specified sections.
4. Select the appropriate option indicating whether you are electing to be exempt from coverage or revoking an earlier exemption. This selection will depend on your current needs regarding coverage under the Louisiana Workers’ Compensation Act.
5. Sign and date the form in the designated signature field. Make sure to print your name and title clearly below your signature.
6. Input your date of birth and/or Social Security number in the corresponding section. This information is vital for identification purposes.
7. Provide your client number and address, ensuring that all information is clear and legible.
8. Enter the name of your insurance agent and the agency name, along with the agency address, city, state, and ZIP code. Correct information here is crucial for processing.
9. To finalize your submission, fax the completed form to the appropriate Underwriting department for your region. Ensure you have included all necessary information before sending.

Complete your documents online to streamline the process.