Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 861 LA (2005/07)
Louisiana Auto Supplement
Active Military Personnel Affidavit
Use this supplement as proof in the form of an affidavit for policy renewals that the named
insured, having previously established eligibility for the insurance premium discount
program for active military personnel stationed in Louisiana mandated by R.S. 22:1425(A),
continues to meet the eligibility requirements.
IDENTIFICATION SECTION Agency
Producers name and address.
IDENTIFICATION SECTION Code
Identification code assigned to your agency or brokerage firm by the insurance company
receiving this form.
IDENTIFICATION SECTION Subcode
If your agency uses a subcode identification system with the company, enter the
appropriate code.
IDENTIFICATION SECTION Named Insured
Insured's name exactly as it appears on the policy.
IDENTIFICATION SECTION Company
Issuing company's name.
IDENTIFICATION SECTION Policy #
Number exactly as it appears on the policy, including prefix and suffix symbols.
IDENTIFICATION SECTION Effective Date
Date on which the terms and conditions of the policy commenced.
AFFIDAVIT
Parish of:
Indicate the name of the parish of the named insured.
AFFIDAVIT
BEFORE ME, the undersigned
authority on this day personally
appeared
Insured's name exactly as it appears on the policy.
Signed this day
Indicate the day in DD format
Month
Indicate the month in MM format
Year
Indicate the year in MMMM format
AFFIDAVIT
Signature of Affiant
Affiant/Named Insured must sign the affidavit.
Subscribed and Sworn to Before
me, the undersigned authority on -
Day
Indicate the day in DD format
Month
Indicate the month in MM format
Year
Indicate the year in MMMM format
AFFIDAVIT
Signature of Notary
Notary must sign the affidavit.
AFFIDAVIT
Print Name
Indicate the name of the notary. If handwritten, please print.
AFFIDAVIT
Address
Indicate the address of Notary. Do not use a P.O. Box
ACORD 861 LA (2005/07)
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