Group Insurance Application
Submitted through:
1821 Sacramento St.
San Francisco, CA 94109

Please complete ALL questions and submit this application to Central Office, together with the administrative fee of $50 payable to Intercounty Fellowship of A.A. Please note: this request form does not automatically bind coverage for the additional insured being requested.

You must have from the facility a written request (or email) requesting insurance. We will submit the application and a Certificate will be sent directly to your landlord, with a copy to Central Office. The contact person listed on the application will be notified when the office has received the certificate.

It is the responsibility of each group to maintain a current contact with Central Office at all times. Updated information can be sent to with “Group Insurance” in the subject line. The administrative fee is $50 and is valid for the remainder of the term policy.
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1. Landlord’s name (as it must legally appear on the Certificate)
Landlord: *
Landlord’s contact person
Landlord’s contact name: *
Landlord's contact mailing address *
Landlord’s contact phone: *
Landlord’s contact email: *
Landlord’s contact fax: *
A.A. Group/Meeting information
Group name, day, time: *
(as it appears in the schedule)
Group address: *
Group contact name: *
Please keep a current name on file with Central Office at all times.
Group contact address: *
Group contact phone: *
Group contact email: *
Number of meetings per week at this location
Number of meetings: *
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