FLA Member Number:

Your Name:

Address:

City:

State: Please Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Phone Number:

Email:

Number of acres you own:

Number of clubs you lease land to:

Do you currently have insurance for Hunt Lease or Vacant Land? Yes No

Current Insurance Renewal Date:

Questions or Comments: