Losey Insurance and Financial Services of Baton Rouge, Louisiana

We encourage you to complete the following form as well as a quote request for the policy you wish to change or renew. We will place your name and request in our diary system and contact you one month prior to your renewal.

Gary Losey

8550 Anselmo Lane

Baton Rouge, LA 70810

Phone: 225-767-6745

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Fax: 225-767-6744

www.LoseyFinancial.com

Any unauthorized use of material contained herein is at the user's own risk. Transmission of the information and material herein is not intended to create, and receipt does not constitute an agreement to create a relationship with Losey Insurance and Financial Services or any member thereof.

Securities offered through Parkland Securities, LLC Member FINRA and SIPC.

Losey Insurance and Financial Services in independent of Parkland Securities, LLC | Address: 8550 Anselmo Lane; Baton Rouge, Louisiana, 70810 | Telephone: (225)767-6745

Form CRS


» Name
Address:
City:
State:
Zip:
» Home Phone:
Work Phone:
» Email:

Policy Number:
Policy change effective date (mm/dd/yy):
Change First Mortgage
Name:
Address:
Loan #:
Is first morgagee maintaining escrow to pay homeowners premium:	Yes No

Change Second Mortgage
Name:
Address:
Loan #:

Comments or other changes (please specify)

Homeowners Service Request