Purchase BPA Field Owner Certificate Rates Effective: 8/1/22 – 8/1/23

Comments or Special Requests:

Certificate Holder Name:
(e.g., field owner, facility owner,city,township,park district, etc)

Certificate Holder Address:

City:

State:

Zip:

Phone:

Fax:

Certificate should be: Faxed Emailed

Email or Fax Number:

To the attention of:

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Premium is fully earned on the effective date of coverage. No pro-rata refunds will be made. Membership includes insurance premiums & association fees. I understand and agree that (a) if this application is accepted by the Company, coverage will begin on the date of acceptance or the date requested in the application, whichever is later, subject to payment of the required premium; and (b) Premium computation is subject to audit. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Please check the box to verify and agree that the information provided herein is true and complete.
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Purchase BPA Field Owner CertificateRates Effective: 8/1/24 - 8/1/25

Purchase BPA Field Owner Certificate
Rates Effective: 8/1/24 - 8/1/25