Group Insurance

For the meetings and groups in the Santa Clara County Fellowship of Alcoholics Anonymous.

Use the download links above to print the insurance application and submit offline. Or, use the form below to submit the application online. If applying online, please call the office at (408) 889-1001 to arrange payment for the premium due.

Certificate issued in three working days after payment received.

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

Meeting facility landlord’s name:(Required)

Enter name as it must legally appear on the insurance certificate

Landlord address:(Required)

Street Address Address Line 2 City State Zip Code

Name of landlord's representative / designated contact for meeting facility:(Required)

First Last

Contact telephone number:

Contact email address:(Required)

Contact fax number:

A.A. Group/Meeting information

A.A. Group or meeting name:(Required)

Number of meetings per week held at this facility:(Required)

Meeting address:(Required)

Street Address Address Line 2 City State ZIP Code

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.

First Last

Contact address:(Required)

Street Address Address Line 2 City State ZIP Code

Contact telephone number:

Contact email address:(Required)

Name

This field is for validation purposes and should be left unchanged.

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Group Insurance

Landlord information

A.A. Group/Meeting information

Title

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Resources

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