Insurance Application

Print out and return to: Buckmasters Liability Insurance
P.O. Box 244022 • Montgomery, Alabama 36124-4022

For specific Information about the Liability Insurance call Starr Cannon: 1-800-240-7283
For assistance completing this form call: DAWN SINGLETON 1-800-240-3337

1. INSURANCE PREMIUM
$242.00

SURPLUS LINES TAX = 6%
$14.52

POLICY FEE =
$35.48

TOTAL DUE SEI =
$292.00

*If over 1,613 acres call 1-800-240-3337 or 1-800-240-7283.

Make this check payable to: SOUTHEASTERN INSURANCE, LLC

Sorry, No Credit Cards!

IMPORTANT:
You will need to send two separate checks. Make them payable as indicated on this form. Combined payments on one check will be returned.

Coverage will become effective upon receipt of completed application with total payment, and expires on the 1st day of your anniversary month or_____________________

Requested Effective Date

• FULLY EARNED PREMIUM ( No Refunds) • NON-TRANSFERABLE

2. ADMINISTRATIVE, LANDOWNER CERTIFICATE AND MEMBERSHIP FEES

ADMINISTRATIVE FEE:
(Total number of acres______X .14) = $______________

LANDOWNER CERTIFICATE FEE:
$20 per landowner.
(Number of landowners______X $20) = $_____________

MEMBERSHIP FEE:
Number of memberships you
are paying for_____________X $27.95 = $______________ (AL Res. $29.07)

TOTAL DUE BUCKMASTERS = $____________________

Make this check payable to: Buckmasters
– or charge to:

CC# _________________________________________

Exp. Date_____________________________________

(Circle One)
• Visa • Master Card • Discover

• Attach a list of your hunting club members' names, membership numbers, addresses and phone numbers to aid in faster processing of your request.

3. LEASE INFORMATION

CLUB NAME______________________________________

Contact Person___________________________________

Address_________________________________________

City_____________________________________________

State____________________Zip_____________________

Phone (__________)_______________________________

LANDOWNERS____________________________________

Address_________________________________________

City_____________________________________________

State____________________Zip_____________________

Phone (__________)_______________________________

LOCATION: State______County/Parish___________________

Number of Acres___________________________________

Legal Description of Property / Use separate sheet if needed.
________________________________________________

_________________________________________________

PLEASE BE SURE TO FILL OUT COMPLETELY AND LEGIBLY.

I CERTIFY THAT THE INFORMATION GIVEN INCLUDING THE ACRES DECLARED AND LIST OF CLUB MEMBERS IS COMPLETE. ANY MISREPRESENTATION COULD JEOPARDIZE MY ABILITY TO COLLECT ON ANY CLAIM.

SIGNATURE REQUIRED:_______________________________________________________________________________