Fillable CACommunityService36-8480 CALIFORNIA Race, National Origin and Gender Endorsement

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CACommunityService36-8480 CALIFORNIA Race, National Origin and Gender Endorsement

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PI CA-CSS-01 (2/07)
CALIFORNIA
RACE, NATIONAL ORIGIN & GENDER FORM
Community Service Statement
Philadelphia Indemnity Insurance Company
Bala Cynywd, PA
# Policyholder Number (for New Business Only)
This information is requested by the State of California in order to monitor the insurer’s compliance with the law. All
new policyholders are requested to voluntarily provide the following information.
No such information shall be used for purposes of underwriting or rating any policyholder.
Policyholder’s Name and Address (to be provided in order to refer back to the policy)
Note: use additional forms if needed.
Policy Type
Fire Personal Fire Commercial
Homeowners Commercial Multi Peril
Private Passenger Auto- Liability
• If policyholder does not wish to provide the Department of Insurance with this information, please check here.
Check the Race or National Origin as it applies to the policyh
older (s). For the purpose of completing this form, the
policyholder
is defined as: individual, spouse, domestic partner, or business partner (s) named on the policy.
POLICYHOLDER CO-POLICYHOLDER
Male Female Business Male Female Business
African- American
American Indian or Alaskan Native
Asian/ Pacific Islander
Latino
White
Other
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CACommunityService36-8480 CALIFORNIA Race, National Origin and Gender Endorsement

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Completed 2 July 2020

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