DAVIS-GARVIN INSURANCE AGENCY
PO BOX 21627
COLUMBIA, SC 29221-1627
TELEPHONE 800-845-3163 FAX 803-781-6712
Landowner Name
Contact Name
Address
City
Telephone
Email Address
Large Landowners
Hunt Lease Liability Application
Desired Effective Date
State
Cell Phone
Zip Code
Fax
Limit of General Liability
$1,000,000 Occurrence / $2,000,000 Aggregate
Damage to Rented Premises - (Optional)
Medical Expense for Non-Participants - (Optional)
$ 50,000 Per Occurrence
None
$ 5,000 Per Person
None
$ 100,000 Per Occurrence
$ 10,000 Per Person
Description(s) of Property
Total number of acres leased
Total number of clubs
Is it the intent of this policy to cover both the landowner and the hunt club?
Yes
No
If yes, a list of clubs providing name, address and acreage by state and county is required.
If no, are clubs required to carry their own insurance?
Yes
No Do you obtain proof of coverage?
Yes
Is the land leased for purposes other than hunting?
Yes
No If yes, please explain in detail
Are any acres sub-leased?
Yes
No It is not the intent of this policy to cover sub-leased acreage.
Any structures on premises?
Yes
No If yes, explain
Prior Insurance
Carrier
Last Year
Two Years Ago
Three Years Ago
Loss History (Past 3 years)
Date
Description of Incident
Limits of Liability
Premium
If no losses, check here
Amount Paid/Reserved
Required Attachments: Loss History Reports for past 3 years. If unavailable, provide a loss statement signed by insured.
A WRITTEN HUNT CLUB LEASE AGREEMENT BETWEEN THE LANDOWNER AND EACH CLUB IS REQUIRED
The information below is required for each Hunt Club. Use page 2 to add additional clubs or provide requested
information in a separate spreadsheet.
Hunt Club Name
Club Representative
Address
City
State
Zip
Number of Acres Leased
County, State
Number of Members
Guests Allowed
Yes
No
Fishing Allowed
Yes
No
Type of Game Hunted
Do you rent or loan saddle animals?
Yes
No
Do you rent or loan ATV / snowmobiles?
Yes
No
Do you rent or sell guns or ammunition?
Yes
No
Insured Signature
Date
Coverage is subject to approval by Davis-Garvin Insurance Agency
Client Code
Large Landowner Hunt Lease Application (05/13) rev.docx
No
Club #
Hunt Club Name
Club Representative
Address
Number of Acres Leased
Number of Members
Guests Allowed
Yes
No
Type of Game Hunted
Do you rent or loan saddle animals?
Do you rent or loan ATV / snowmobiles?
Do you rent or sell guns or ammunition?
Club #
Hunt Club Name
Club Representative
Address
Number of Acres Leased
Number of Members
Guests Allowed
Yes
No
Type of Game Hunted
Do you rent or loan saddle animals?
Do you rent or loan ATV / snowmobiles?
Do you rent or sell guns or ammunition?
Club #
Hunt Club Name
Club Representative
Address
Number of Acres Leased
Number of Members
Guests Allowed
Yes
No
Type of Game Hunted
Do you rent or loan saddle animals?
Do you rent or loan ATV / snowmobiles?
Do you rent or sell guns or ammunition?
Club #
Hunt Club Name
Club Representative
Address
Number of Acres Leased
Number of Members
Guests Allowed
Yes
No
Type of Game Hunted
Do you rent or loan saddle animals?
Do you rent or loan ATV / snowmobiles?
Do you rent or sell guns or ammunition?
Client Name
City
State
County, State
Fishing Allowed
Yes
Yes
Yes
Yes
No
No
No
No
City
State
Zip
County, State
Fishing Allowed
Yes
Yes
Yes
Yes
No
No
No
No
City
State
Zip
County, State
Fishing Allowed
Yes
Yes
Yes
Yes
No
No
No
No
City
State
Zip
County, State
Fishing Allowed
Yes
Yes
Yes
Yes
No
No
No
Client Code
Coverage is subject to approval by Davis-Garvin Insurance Agency
Large Landowner Hunt Lease Application (05/13) rev.docx
Zip
No