2021 AMYA Pond Owners Insurance

2021 AMYA Pond Owners Insurance
Sanctioned Club Number *
Sanctioned Club Name *
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 if email is not available) *
example@example.com
Address of pond owner to appear on certificate *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your Name *
Your Email *
example@example.com
Your Phone Number *
Please enter a valid phone number.
I have contacted the pond owner or represenative for current information. This includes pond owners or represenative name, address, email address and phone number.
Date *

Month Day Year
Clubs using 5 to 10 payment must list all club members in this area for audit.
PAYMENT Can be made with PayPal or

by sending a check to AMYA Treasurer John Skerry
PayPal or Credit Card Payment
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Clubs 5 to 10 members
$ 85.00

Clubs 11 to 45 members
$ 145.00

Clubs over 45 members
$ 200.00

Total

$ 0.00
I will send payment by check to AMYA Treasurer John Skerry 26B Vine St Gloucester MA 01930 TODAY. Make check out to AMYA.

Clubs 5 to 10 Members $85.00 Clubs 11 to 45 Members $145.00 Clubs over 45 Members $200
I am applying for an additional pond
Should be Empty: