Get Adobe Acrobat Reader
 
Download the application in PDF format.

If you live in Massachusetts or Pennsylvania,
telephone or E-mail us for this form.

Telephone: (800) 334-0652 or (805) 963-6624 / E-mail: lia@liability.com

For all other states, print, complete and sign this form.
Please mail or fax to:

Liability Insurance Administrators
1600 Anacapa Street
P.O. Box 1319
Santa Barbara, CA 93102-1319

Fax: (805) 962-0652