Page 22 - Tree Line - North Carolina Forestry Association - Third Quarter 2023

PLEASE FILL OUT AND RETURN WITH PAYMENT
NOTE: This form is for NEW hunt clubs. Existing clubs and landowners need to contact the NCFA office at (919) 834-3943.
In order to obtain a hunting lease or timberland insurance, all parties have to be a member of the NCFA.
NCFA’s Hunting Lease
Liability Insurance Application
APPLY ONLINE
NAME OF HUNT CLUB:____________________________________________________________________________________
Contact:________________________________________________________________NCFAMember#: _________________
Address: __________________________________________________________________________________________________
City: ____________________________________________ State: ______________ ZIP Code: _________________
Phone: _______________________________________________________________________________________
E-mail: ________________________________________________________________________________________
The club must have a written lease with all landowners for coverage to apply.
NAME OF LANDOWNER: _________________________________________________ NCFA Member #:______________ (person, partnership or corporation)
Landowner Representative (If different from above):___________________________________________________
Address: _________________________________________________________________________________________________
City: ____________________________________________ State: ______________ ZIP Code: _________________
Phone: ________________________________________________________________________________________
E-mail: ________________________________________________________________________________________
Total Number of Acres: ____________________ County: ______________________________________________
Leasing from more than one landowner? Please attach a separate sheet with the above information for each landowner.
PREMIUM CALCULATION: COMPLETE OPTION 1 OR 2 (please check one)
OPTION 1: $1 Million General Liability Limit OPTION 2: $2 Million General Liability Limit
ACREAGE
✔
OPTION 1 PREMIUM
✔
OPTION 2
$2 MILLION PLAN
ACREAGE
✔
OPTION 1 PREMIUM
✔
OPTION 2
$2 MILLION PLAN
Less than 500 1001-1500 2001-2500
$215.00 $400.00 $295.00 $545.00 $465.00 $860.00
3001-3500 4001-4500 Above 5000
$600.00 $775.00 $0.16 / Acre
$1,110.00 $1,435.00 $0.30 / Acre
Date:______________
501-1000
$245.00
$455.00
3501-4000
$675.00
$1,250.00
1501-2000
$380.00
$705.00
4501-5000
$815.00
$1,510.00
2501-3000
$520.00
$965.00
Signature of Landowner: _____________________________________________________
Please make check for insurance payable to AssuredPartners or visit www.apoutdoorinsurance.com to apply & pay online. Mail form and payments to: Assured Partners, P.O. Box 21627, Columbia, SC 29221
Coverage is subject to approval by AssuredPartners. Master Policy effective date is August 1 to August 1. Applications received after August 1 of a given year will be effective upon approval and will expire on the following August 1.
20 ncforestry.org / THIRD QUARTER 2023