MEDICAL
MARIJUANA
INSURANCE
APPLICATION

WE RESPECT YOUR PRIVACY!

PLEASE DOWNLOAD, FILL OUT THE APPLICATION AND FAX IT TO OUR OFFICE AT (800) 920-4107 OR CALL US FOR MORE INFORMATION:

Gaslamp Insurance
Attn: MMJ Insurance Program manager
1111 6th Avenue, 3rd Floor
San Diego, CA 92101
Tel. (800) 920-4125 extention 205
Fax. (800) 920-4107

Email: mmjprogram@mmjinsurance.com

CONFIDENTIALITY NOTICE

E-mail sent through the Internet is not secure nor accepted by us as official notification for any reason. Accordingly, do not use e-mail for any official notification including, but not limited to: (1) sending orders to bind or modify coverage; (2) submitting information about insurance claims we are handling; (3) submitting payroll related instructions; or (4) sending any time sensitive instructions. We will not accept such orders, instructions, or information via e-mail. Do not use e-mail to send us confidential information. Confidential information includes, but is not limited to bank account numbers, social security numbers, DMV information, and changes of address. We take your PRIVACY seriously.