Group Insurance

Submitted through: INTERGROUP CENTRAL OFFICE OF SANTA CLARA COUNTY, INC. 274 E. Hamilton Ave., Suite D Campbell, CA 95008 Tel: 408-374-8511 Email: [email protected] Insured: INTERGROUP CENTRAL OFFICE OF SANTA CLARA COUNTY, INC. Policy Number: 202101753NPO Please complete ALL questions. This request form does not automatically bind coverage for the additional insured being requested.

Landlord information

Enter name as it must legally appear on the insurance certificate
Landlord address:(Required)
Name of landlord's representative / designated contact for meeting facility:(Required)

A.A. Group/Meeting information

Meeting address:(Required)
Name of A.A. group’s designated liaison to landlord:(Required)
This might be the steering committee chair, or a meeting secretary. This liaison information must be kept current at Central Office.
Contact address:(Required)
This field is for validation purposes and should be left unchanged.