Request Annual Certificate of Insurance

Use this form if you need to permanently add a land owner to an existing certificate or request a new certificate.

Name of Applicant or Insured *
Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Contact Name *
First Last
Contact Phone *
### - ### - ####
Email where certificate is to be sent *

Send to a club member, do not send directly to the landowner.

Confirm Email
Landowner Details
Landowner (Name) *

Provide the full legal name of the landowner/ town / municipality etc.
Landowner Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

This is the business or home address of the Landowner. NOT THE PROPERTY ITSELF unless the two are the same.
General Comments (if required)
Applicant Signature: *
Name of signature above*
First Last
Date Signed *
By checking the box below you are certifying the information contained within this form to be accurate and correct. *

I understand and agree