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Providing Protection since 1956
California License #0258232

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Basic Information Church Name

Website

Contact First

Last Name

Title

Primary Contact Email

Phone

Main Contact

Ext

Fax

Street Address Address Line1

Address Line2

City

State

Zip

Mailing Address - Same Address Line1

Address Line2

City

State

Zip

Supplemental Information Denomination
Number of Members
Federal Tax ID
Is this a 'Not for Profit' organization?

Name of Insurance Carrier
Type of Insurance Policy

(Package, Property, Liability, Workers Compensation, Business Auto, Umbrella Liability, Fine Arts, Other)

Renewal Date
Annual Premium
Any claims in the past three years?

Has any coverage been declined or non-renewed in the past three years?

Operations House of worship?
Office?
Headquarters
Day Care?
School?
Social Services (Counseling, Rehabilitation)?

A. Mason Blodgett & Associates, 100 Pringle Avenue, Suite #420, Walnut Creek, CA 94596
Tel. 925-300-4505 Toll-Free 800-979-5002 Fax 925-977-1660