Page 27 - North Carolina Forestry Association - Fall 2019

PLEASE FILL OUT AND RETURN WITH PAYMENT
NCFA’s Hunting Lease
Liability Insurance Application
NAME OF HUNT CLUB: __________________________________________________ # of Members: ___________ Club Official to Receive Certificate of Insurance: ____________________________________________________ Mailing Address: _______________________________________________________________________________ City:____________________________________________ State:______________ ZIP Code:________________ County: _______________________________________________________________________________________ Work Phone:_____________________________________ Home Phone: _________________________________
Dues: $75 Payment Enclosed
Please check here if annual dues have already been paid.
NOTE: no coverage is in effect until all money is received by the NCFA. Coverage cannot be back dated.
NAME OF LANDOWNER (person, partnership or corporation):____________________________________________ Landowner Representative (If different from above):__________________________________________________ Mailing Address: _______________________________________________________________________________ City: ____________________________________________ State: ______________ ZIP Code: ________________ County: _______________________________________________________________________________________ Work Phone:_____________________________________ Home Phone: _________________________________
Dues: $50 Payment Enclosed (plus $.025 per acre for acres over 500) Please check here if annual dues have already been paid.
LAND INFORMATION
Total Number of Acres: ___________________ County: _____________________________State: ___________
HUNTING LEASE RATES (please check one)
✔
ACREAGE RANGE
PREMIUM FOR CLUB
Less than 500
$180.00
501-1000
$255.00
1001-1500
$300.00
1501-2000
$380.00
2001-2500
$430.00
2501-3000
$480.00
✔
ACREAGE RANGE
PREMIUM FOR CLUB
3001-3500
$560.00
3501-4000
$635.00
4001-4500
$720.00
4501-5000
$755.00
> 5000
$0.15 Per Acre
ncforestry.org / THIRD QUARTER 2019 25