Ken Schnauder, Executive Director

Tel: (225) 362-5262
Fax: (225) 362-5265
Email: Ken.Schnauder@la.gov

Physical Address:
8225 Florida Blvd., 2nd Floor
Baton Rouge, Louisiana 70806
1-866-469-9555
225-362-5400

Mailing Address:
P.O. Box 3718
Baton Rouge, Louisiana 70821

Get A Game Plan Louisiana Recovery Authority LaTrac

Applications

Click on the application name to view/print any application.
ALL NEW APPLICATIONS

A signed application is needed so please print out the signature page, sign it and submit it to our office.  It will be matched to your application submitted electronically.

 Click Here to Submit Applications Online

 

PRIMARY INSURANCE

 

Forms for MDs & Advanced RNs with Primary Insurance

PCF1

Application for MDs & Advanced RNs 

PCF9

Application for Corporations 

PCF10

Procedure Questionnaire for Those with “Minor” or “Major” Surgery Designation 

PCF11

Questionnaire for Those with Limited or No Practice in Louisiana 

PCF12

Part-Time Questionnaire 

PCF15

Additional Insured Addendum 

 

Forms for Dentists and Oral Surgeons with Primary Insurance

PCF2

Application for Dentists and Oral Surgeons  

PCF9

Application for Corporations 

PCF11

Questionnaire for Those with Limited or No Practice in Louisiana 

PCF12

Part-Time Questionnaire 

PCF15

Additional Insured Addendum 

 

Forms for Hospitals and Nursing Homes with Primary Insurance

PCF3

Application for Hospitals and Nursing Homes 

PCF9

Application for Corporations 

PCF14

Application for Management Companies 

PCF15

Additional Insured Addendum 

 

Forms for Non-MDs with Primary Insurance (Chiropractors, Optometrists, Pharmacists,

Physical Therapists, Psychologists, etc.)

PCF4

Non-MDs (Chiropractors, Optometrists, Pharmacists, Physical Therapists, Psychologists, etc.) 

PCF9

Application for Corporations 

PCF11

Questionnaire for Those with Limited or No Practice in Louisiana 

PCF12

Part-Time Questionnaire 

PCF15

Additional Insured Addendum 

 

Forms for FTE’s, Locum Tenens, Clinics, ER Groups and Surgical Centers with Primary Insurance

PCF5

Application for FTE’s, Locum Tenens, Clinics, ER Groups and Surgical Centers 

PCF9

Application for Corporations 

PCF14

Application for Management Companies 

PCF15

Additional Insured Addendum 

 

SELF INSURANCE

 

Forms for Healthcare Professionals with Self Insurance

PCF6

Healthcare Professional Application 

PCF9

Application for Corporations 

PCF11

Questionnaire for Those with Limited or No Practice in Louisiana 

PCF12

Part-time Questionnaire 

PCF13

Pledge Agreement for Self Insured Providers 

PCF15

Additional Insured Addendum 

 

Sample Letter of Credit  

 

Forms for Hospitals with Self Insurance

PCF7

Institutional Health Care Provider Application 

PCF9

Application for Corporations 

PCF13

Pledge Agreement for Self Insured Providers 

PCF14

Application for Management Companies 

PCF15

Additional Insured Addendum 

 

Sample Letter of Credit  

 

Forms for Nursing Homes and Assisted Living Facilities with Self Insurance

PCF8

Nursing Home and Assisted Living Facility Application 

PCF9

Application for Corporations 

PCF13

Pledge Agreement for Self Insured Providers 

PCF14

Application for Management Companies 

PCF15

Additional Insured Addendum 

 

Sample Letter of Credit