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Division of Life and Annuities And Long Term Care

Insurance Company Contact Request Form - Online Submission


To electronically submit the Insurance Company Contact Request Form to the Louisiana Department of Insurance, please fill out the fields below:

Date of request

* Required fields
Information of the Deceased
First Name: *  
Middle Initial: 
Last Name: *  
Street: *  
City: *  
State: *  
Zip: *
Date of Birth: *
Date of Death: *
Social Security Number:

Inquirer's Information
Email Address: 
First Name: *  
Middle Initial: 
Last Name: *  
Street: *  
City: *  
State: *  
Zip: *
Relationship to Deceased: *  
Daytime Phone Number: *
Any Additional Information:

Death Certificate Submission

Instructions: To attach a copy of the Death Certificate, click on the browse button below. A window will appear which will allow you to browse through your local computer to find the correct file. Select the file and click the Open button. 

Please only use jpg, tif, gif, bmp, png or wmf image formats.

Attached Death Certificate:  

Opt Out Method: If you do not wish to submit a copy of the Death Certificate online, please check the opt-out option and then select a method below that you wish to use to send the certificate. 

Death Certificate Submission Method: Please select a send method.

Your request cannot be handled without a copy of the death certificate. If it is not submitted online, then it must be submitted by one of the other options listed below.

  If Other, type method here:  


Contact Information:

Sam Brooks, Assistant Director
(225) 342-1253

Mailing Address:

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

Fax Number:  (225) 342-7401