AFFTA Liability Insurance Questionnaire

* required field

Applicant Information

Effective Date *
Business Name  
Business Type *
Applicant Name *
Outfitter License #  
Guide License #  
Mailing Address *
Physical Address *
City *
State Zip
Phone Number *
Email *


Annual Premium Indication Rates

(Premiums cannot be pro-rated. Refunds subject to agency discretion.)

Prior Losses (check for yes)
If yes, provide details below and submit. Coverage may not be bound.
Gross Sales* $
  Rate   # Line Total
Outfitter (includes non-motorized boat) $400 Number of Outfitters $
Guide (includes non-motorized boat) $400 Number of Guides $
W2 Employee guide(s) $175 Number of Empl Guides $
Please list all W2 employee names below:
1099 Independent guide(s) $75 Number of 1099 Guides $
Please list all independent guide names and mailing addresses below:
Subtotal:       $
Optional Coverage offered with additional premium due:
Bird hunting $200 (check for coverage) $
Big Game hunting (non-horseback) $200 (check for coverage) $
Motorized boats (fill in section below) $107 Number of boats $
Boat Information (motorized)

“Motorized” means any watercraft using a motor, either in-board or outboard.
Boats over 20ft or motors over 100 Horsepower: Call 406-586-6230 for approval. Covers commercial use only, not personal use.

Year Make/Model Feet HP Inboard/Outboard Top MPH


Operators Information
Name Age Drivers License # Last 3 years Accidents/Violations
Rental boats, non-motorized $75 Number of boats $
Non-governmental Additional Insured $25 Number additional insured $
Additional Insureds

Provide name & address of each governmental agency or business/individual you want as an additional insured (AI) on your policy.

Name Address

For full coverage on boats or equipment (covers commercial use only, not personal use)
Physical damage/theft coverage: $500 Deductible; Premium: $1.00 per $100 of value ($10.00 / $1000) No Minimum Premium

  Year/Make/Model Serial Number Current Value
Boats $
Trailers $
Equipment $
Additional Insurance Total $


Insurance Total (REQUIRED)
  * $

If you live in California, Louisiana, New Jersey, North Carolina, Maine, Florida, Texas, or Vermont there will be an additional insurance state tax. Depending on the State the tax could be up to 5%. Please contact our office if you would like additional information.




* I certify I am a AFFTA member
* Checking this box represents your signature on this application. In addition you are hereby agreeing to the terms and conditions set forth by this application and contract of insurance.

Additional Information

Annual Premium Indication Rates

(Premiums cannot be pro-rated. Refunds subject to agency discretion.)

Insurance Limits
$1,000,000 limit per Outfitter or Guide for each liability event
$2,000,000 yearly total liability limits per Outfitter or Guide for all liability events
$5,000 client non-fault medical limit per event
$250 deductible for property damage/loss liability (client gear)

Acitvities Not Covered Under Policy

The AFFTA liability insurance policy is intended to cover fishing operations and related services ONLY. If you provide any of the activities below and want additional coverage, the activity or activities MUST be insured separately. Please contact Bissell Agency for more information.

  • Equine liability
  • Retail operations, including internet sales
  • Deep sea fishing
  • Lodging Operations
  • Whitewater rafting not involving guided fishing
  • Non-motorized boats over 26 ft. in length
  • Outfitter/guide gear (boat, trailer, boat gear, rods, reels, flies, etc.) Optional gear coverage available - use Optional Insurance form.


CLIENT ACKNOWLEDGEMENT OF RISK FORMS REQUIRED! Signed forms must be available in event of an insurance audit or claim. Keep forms for 3 years after client signs. These signed forms augment Montana law regarding acknowledgement of risk.

The coverage information contained in this questionnaire is only a general description and is not a statement of contract. In the event of a claim, any coverage provided by the Insurer is subject to Terms, Conditions, and Exclusions in actual policy. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or material thereto, commits a fraudulent insurance act which is a crime and may subject such person to criminal and civil penalties.

***** Your insurance is effective upon receipt of premium payment and insurer approval. *****


Policyholder Disclosure
Notice of Terrorism Insurance Coverage


Under the Terrorism Risk Insurance Act of 2002, as amended pursuant to the Terrorism Risk Insurance Program Reauthorization Act of 2007, effective January 1, 2008 (the "Act"), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 1 02(1) of the Act: The term "certified acts of terrorism" means any act that is certified by the Secretary of the Treasury-in concurrence with the Secretary of State, and the Attorney General of the United States-to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission; to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.

You should know that where coverage is provided by this policy for losses resulting from "certified acts of terrorism," such losses may be partially reimbursed by the United States Government under a formula established by federal law. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear events. Under the formula, the United States Government generally reimburses 85% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage is provided below and does not include any charges for the portion of loss that may be covered by the Federal Government under the Act.

You should also know that the Act, as amended, contains a $100 Billion Cap that limits United States Government reimbursement as well as insurers' Liability for losses resulting from "certified acts of terrorism" when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced.


The federal Terrorism Risk Insurance Program Reauthorization Act of 2007 is scheduled to terminate at the end of December 31 , 2014, unless renewed, extended or otherwise continued by the federal government. Should you select Terrorism Coverage provided under the Act and the Act is terminated December 31 , 2014, any terrorism coverage as defined by the Act provided in the policy will also terminate.


NOTE: In the state of Wisconsin only, a terrorism exclusion makes an exception for (and thereby provides coverage for) fire losses resulting from an act of terrorism. Therefore, if you reject the offer of terrorism coverage, that rejection does not apply to fire losses resulting from an act of terrorism coverage for such fire losses will be provided in your policy.


I hereby elect to purchase certified terrorism. I understand that the federal Terrorism Risk Insurance Program Reauthorization Act of 2007 may terminate on December 31, 2014. Should that occur my coverage for terrorism as defined by the Act will also terminate.


I hereby reject the purchase of certified terrorism coverage.


Policyholder/Applicant's Signature. Checking this box represents your signature.


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