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What forms are needed in the state of Louisiana?

The available forms are listed below. You can open a .pdf version of these forms by clicking on the desired form number in the 'File Attachments' section below.

State of Louisiana Uninsured/Underinsured Motorist Bodily Injury Coverage Form: AU LA39 0609

If you have not previously completed and signed the selection/rejection of Uninsured/Underinsured Motorist Bodily Injury Coverage form or if you want to make changes to your current coverage, please print and complete this form. Use form AU LA39 0609 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century North America Insurance Company (35) or 21st Century Centennial Insurance Company (54).

State of Louisiana Uninsured/Underinsured Motorist Bodily Injury Coverage Form: AU LA39a 0609

Use form AU LA39a 0609 if your policy declaration page indicates that the insurance company issuing your policy is 21st Century Premier Insurance Company (55).

Selection of Uninsured Motorists Property Damage - Louisiana: LA-NOT (1/12)

For all other correspondence, once completed, please mail or fax the form to the address or fax number listed below.

Physical Mailing and Overnight Address:

Overnight - Correspondence
21st Century Insurance
3 Beaver Valley Rd - 4th Floor
Wilmington, DE 19803

Fax number: 1(866) 447-2611

File Attachments

LA UM/UIM BI Coverage Selection Form.pdf
LA UM/UIM BI Coverage Selection Form a.pdf
Selection of UM PD - LA.pdf

Topics

General Information
Coverage
State Forms

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