AMYA Pond Owners Insurance

2023 AMYA Pond Owners Insurance
Your Sanctioned Club Name*
Your Club Number Is
Name or Title of Pond Owner, Municipality or Agency to appear on certificate*
Name of pond owner or person representing the pond owner*
Phone Number of pond owner or person representing pond owner*
Please enter a valid phone number.
Email address of pond owner or person representing pond owner (fax number only if email is not available)*
example@example.com
Address of pond owner to appear on certificate*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Name*
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.
READ AND COMPLETE*

I have contacted the pond owner or representative for current information. This includes pond owners or representatives name, address, email address and phone number. I understand that any incorrect information may delay the pond owner's certificate of insurance.
Date*

MonthDayYear
Clubs using 5 to 10 payment must list all club members in this area for audit.
PayPal or Credit Card Payment
prevnext( X )
Clubs 5 to 10 members
$100.00



Clubs 11 to 45 members
$170.00



Clubs over 45 members
$230.00



Total

$0.00
PAYMENT Can be made with PayPal or

by sending a check made out to AMYA and mail to Robert D. Shapiro, 8 Webber St, Wilmington, MA 01887
If you're not paying by PayPal or Credit Card check below the number of club members and send check made out to AMYA today to Robert Shapiro AMYA Treasurer.

Then Submit
I will send payment by check made out to AMYA and send it to Treasurer Robert D. Shapiro, 8 Webber St, Wilmington, MA 01887 TODAY. Make check out to AMYA.

Clubs 5 to 10 Members $100.00Clubs 11 to 45 Members $170.00Clubs over 45 Members $230.00
If you are applying for an additional pond there is no charge. Please check the button below " I am applying for an additional pond" and submit.
I am applying for an additional pond
Should be Empty:

2023 AMYA Pond Owners Insurance