Form 03-01

Authorized Employer Contacts

Please complete all sections. Signatures are required for designated authorized signers. Designate personnel who will be responsible for certifying or viewing data. The designated personnel should be familiar with the accuracy of the data, as the employer will be responsible, under the provisions of La R.S. 11:1201-B, for any errors that result from incorrect certifications. Personnel with "Inquiry Only" access will not be an authorized signer. Exception: the Superintendent/Agency Head is an "Authorized Signer," even with "Inquiry Only" access. Always allow pop-ups from this site

Upon completing the Form 03-01, all listed agency personnel will receive an email requiring confirmation of their email address. It is imperative that all listed agency personnel confirms their subscription for LSERS email list service. LSERS provides important information and updates through email and, without confirmation, it will hinder agency personnel from gaining valuable LSERS information. Procedures provided at here will supply a step-by-step process on what is required to confirm the email subscription. Ensure your agency staff is aware they have been authorized access to LSERS inquiry and/or other online forms. LSERS does not share agency email addresses with any third party vendor.

Legend for access requests: I - Inquiry Only   E - Enrollment    T - Termination   A - Address   C - CCR/4C/Ins Ded/Sal Contr

Employer Information
Employer Name:
Employer ID Number:
Agency Website Address:
Employer Address:
Telephone Number:
City, State, Zip:
Fax Number:
Information on Designated Personnel
Designee First Name:
Designee Last Name:
Requests access to (check all that apply)
Inquiry Only cannot also have
permission to make changes.
Replaces previously designated personnel? Name to be deleted from list:
Position or Title: Phone Number/Ext:

Date Signed:

E-mail address:
Employer Certification
Agency Head First Name:
Agency Head Last Name:
Agency Head Signature:

Date Signed: