Mixed Martial Arts Insurance, Boxing Events Accident Insurance

Policy Holder Information

Full Legal Name*

As it will appear on Policy Documents.

Address*

Street Address City State ZIP Code

Contact First Name*

Contact Last Name*

Phone*

Email*

Event Information

Name of Event*

Date of the Event*

Location of the Event*

Street Address City State ZIP Code

Insurance and Premium Rates

All premium rates are per event
12 bouts per event limit (quotations available for larger events)
All events are limited to 1 day (quotations available for longer events)
If any of the bouts are Professional, the Professional rate is required. Amateur premium rates only are applicable to 100% amateur bouts.
Coverage in all states except Nevada will be issued on an excess basis. In the State of Nevada, coverage is issued on a primary basis.

Amateur or Professional*

Event Type*

Amateur Rate Plans*

Please refer to our documentation on rate plans to choose a plan: View Amateur Rate Plans (PDF)

Professional Rate Plans*

Please refer to our documentation on rate plans to choose a plan: View Professional Rate Plans (PDF)

Amateur / Professional Rate Plans*

Please refer to our documentation on rate plans to choose a plan: View Professional Rate Plans (PDF)

Limitations*

With Limitations
- Hospital Room and Board & Ancillary Hospital expenses limited to $500 per day up to a maximum of 5 days.
- Medical Emergency Care (room and supplies) expenses including the attending Physician’s charges, x-rays, laboratory procedures, use of the emergency room and supplies, limited to $1,000 maximum per accident.
- Outpatient diagnostic x-rays, laboratory procedures and test expenses including diagnostic imaging expenses, including magnetic resonance imaging (MRI) and CAT scans, limited to $500 per accident.
- Physiotherapy (physical medicine) expense, limited to $50 per visit up to a maximum of 5 visits per accident.
Without Limitations (20% premium increase)

Addition to Total (Without Limitation Adjustment)

Price: $0.00

Premium Total

$0.00

Additional Information

How did you hear about us?*

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not in force until accepted by Anthony Insurance Services, Inc. Coverage is subject to the receipt of payment of the required premium by Anthony Insurance Services, Inc.

Coverage will begin on the date of acceptance or on the date requested, whichever is later. I understand that the premium is fully earned upon policy inception.

Terms & Conditions*

I have read and agree with the Terms & Conditions.

Yes

Authorized Electronic Signature*

Payment Options

Payment*

I do not wish to purchase coverage today. I would like to receive follow-up from Anthony Insurance Services, Inc.
Please charge my credit card for the Total Policy Premium Due Today plus the administration fee of $10.00.

Administration Fee Amount

Price: $10.00

Administration Fee:

A $10 administration fee is added to all policy premium payments.

Total Due Today

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

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