LOUISIANA PATIENT’S COMPENSATION FUND
CORPORATION APPLICATION
(for those with underlying self-insurance and primary insurance)

Required field notice: Fields marked "Required" must be completed.

NAME AND PHYSICAL ADDRESS OF CORPORATION

Corporation Name

Corporation's Physical/Street Address Line 1 (no P.O. Box)

Address Line 2

City, State Zip Code

Dates of Enrollment Applying for:

Enrollment Dates are Required and Must Coincide with Dates of Underlying Coverage

LIST ALL OWNERS, CO-OWNERS, SHAREHOLDERS AND/OR PARTNERS OF THIS CORPORATION
Name	Title

For Self Insured:

I further certify that the appropriate security (proof of financial responsibility) is in place and current at the following institution:

	in the name of

For those with primary insurance, please provide a copy of the COI or declarations page from the insurer’s policy evidencing coverage for the corporation.

Name of Employees (other than owners) including contract employees. Only list employees who are eligible to enroll in the Fund (healthcare providers)	Title and/or Association

Please mail or fax to:

LOUISIANA PATIENT'S COMPENSATION FUND
P.O. BOX 3718
BATON ROUGE, LA 70821

FAX: (225) 342-5593

Signature of AUTHORIZED REPRESENTATIVE -- NOT VALID WITHOUT SIGNATURE

Date

CONTACT PERSON AND PHONE NUMBER:

EMAIL ADDRESS:

A PRINTED, SIGNED COPY OF THIS FORM MUST BE MAILED/FAXED TO PCF.

PCF coverage is subject to all agreements, conditions and exclusions of the underlying policy unless such agreements, conditions and exclusions are expressly prohibited by law.

Additional forms may be found on the LAPCF website: www.lapcf.info

Any questions regarding this form may be emailed to: pcf-surcharge@la.gov