Tripoli Insurance Office
Jeffrey Barnes
3260 Southgate PL SW
Cedar Rapids IA 52404
FAX #319-365-3385

Dear Mr. Barnes;

I would like to take advantage of the $1,000,000 landowner liability insurance that Tripoli offers landowners for use of their property for the purposes of launching rockets. There is no charge for this insurance and is offered for free to protect the landowner from any potential liability. A certificate of insurance will be issued to the landowner(s) listed below. Thank you for your support.

Landowner Name:_____________________________________________

Address:_____________________________________________________

City:________________________State:________ZIP:________________

Daytime Phone:_______________________________________________

Landowner Signature:__________________________________________

Dated:________________

Landowner Name:_____________________________________________

Address:_____________________________________________________

City:________________________State:________ZIP:________________

Daytime Phone:_______________________________________________

Landowner Signature:__________________________________________

Dated:________________

This form is being filed for Tripoli Prefecture #______  Member Name/#_____________________