Discount Medical Plan Organization Application - Louisiana ...

L O U I S I A N A D E P A RT M E N T O F I N S U R A N C EJ A M E S J. D O N E L O NC O M M I S S I O N E RAPPLICATION TO ACT AS ADISCOUNT MEDICAL PLANIN THE STATE OF LOUISIANAGENERAL INFORMATION (Type or Print)APPLICANT NAME:TRADE NAME:FEI OR SOCIAL SECURITY NO.:DOMICILE: ____________________________HOME OFFICE ADDRESS:CONTACT NAME: ________________________________________CONTACT TITLE:CONTACT ADDRESS:PHONE:FACSIMILE:EMAIL:† This Office will communicate only with the named contact person.FEESInitial Application $ 250.00APPLICATION TO ACT AS A DISCOUNT MEDICAL PLANPage 5 of 12(REV 10/2008)