Page 23 - Tree Line - North Carolina Forestry Association - Third Quarter 2021

PLEASE FILL OUT AND RETURN WITH PAYMENT
Timberland Liability
Insurance Coverage Information
AVAILABLE TO LANDOWNERS IN NORTH CAROLINA, SOUTH CAROLINA & VIRGINIA.
The North Carolina Forestry Association’s Timberland Liability Insurance is designed to cover general risks associated with being a landowner. The one-year policy is effective August 1 and expires August 1 of the following year. Coverage is for liability claims arising from timberland ownership, including invited and uninvited guests.
The policy names the landowner as the insured. Landowners will receive a certificate of insurance. Landowners must be a member of the NCFA to purchase this timberland insurance coverage. The NCFA annual membership for landowners is $50 for ownership up to 500 acres, plus $.025 per acre for any acreage above 500 acres.
If you are unsure of your member status, please contact the NCFA at 919-834-3943.
Application - Timberland Liability Insurance
TIMBERLAND LIABILITY INSURANCE HIGHLIGHTS:
• AdmittedCarrier(ARated)
• ComprehensiveGeneralLiability
• Liability Limit: $1,000,000 each occurrence/$2,000,000 aggregate
• Deductible: $0 per occurrence
• Liabilitycoverageforthelandowner does not provide protection for owned timber
Landowner Name: ___________________________________________________________________________________________ Contact Name:____________________________________________ Fed ID / SSN: _____________________________________ Address: ___________________________________________________________________________________________________ City:_________________________________________________State: _______________ ZIP: ____________________________ Telephone (Work): _____________________ (Home):___________________________(Cell): ____________________________ Location (County): ____________________________________ Number of Acres: _____________________________________ How is this property used:____________________________________________________________________________________ Describe any past losses: ____________________________________________________________________________________ ___________________________________________________________________________________________________________
Circle one
Any commercial or business operations of any kind conducted on the premises?.......................................... Any of this property leased for farming? .................................................................................................. Any of this property leased for hunting (private or commercial)?................................................................. If yes to any of the above questions, do you require them to secure coverage elsewhere
and provide a certificate of insurance naming you as additional insured?................................................
Any of this property ever used for mining or containing gas or oil wells? ......................................................
Is this property fenced or posted?...........................................................................................................
Any lakes or ponds on this property?.......................................................................................................
Any dams / spillways / bridges on this property? .......................................................................................
Any watercraft or docks on this property? ................................................................................................
Any buildings, structures, towers or housing accommodations on this property?...........................................
If yes, where are building, structures, towers or housing accommodations insured? ______________________________________ ______________________________________________________________________________________________________________
Premium Calculation – Timberland Liability Insurance
Number of acres to be covered _________ X .31 cents per acre = Premium Due $ ______________________________________ Client Code: NORTCAR-03 (Subject to $200 Minimum Premium)
Signature of Landowner: _______________________________________________________ Date: _______________________
Please make check for insurance payable to North Carolina Forestry Association (NCFA) Coverage is subject to approval by Assured Partners. Master Policy effective date is August 1, to August 1. Premiums are fully earned — no refunds will be issued.
North Carolina Forestry Association – Landowner Membership Dues
$50.00 plus $.025 for acreage over 500 acres = ________
Please make check for landowner membership dues payable to NCFA.
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ncforestry.org / THIRD QUARTER 2021 21