Page 22 - Tree Line - North Carolina Forestry Association - Fourth Quarter 2022

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
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 RANGE
Less than 500 1001-1500 2001-2500
$200.00 $370.00 $280.00 $520.00 $440.00 $815.00
3001-3500 4001-4500 More than 5000
$575.00 $740.00 $0.15 / Acre
$1,065.00 $1,370.00 $0.28 / Acre
Date:______________
✔✔ ✔✔
OPTION 1
$1 MILLION PLAN
OPTION 2
$2 MILLION PLAN
501-1000
$235.00
$435.00
3501-4000
$650.00
$1,205.00
1501-2000
$360.00
$670.00
4501-5000
$775.00
$1,435.00
2501-3000
$495.00
$915.00
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, 2022 to August 1, 2023. Applications received after August 1, 2022 will be effective upon approval and will expire on August 1, 2023.
ACREAGE RANGE
OPTION 1
$1 MILLION PLAN
OPTION 2
$2 MILLION PLAN
20 ncforestry.org / FOURTH QUARTER 2022