Policy Holder InformationFull Legal Name*As it will appear on Policy Documents.Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact First Name*Contact Last Name*Phone*Email* Event InformationName of Event*Date of the Event* Date Format: MM slash DD slash YYYY Location of the Event* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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*AmateurCombined Amateur & ProfessionalProfessionalEvent Type*Mixed Martial ArtsKickboxingBoxingWrestlingAmateur Rate Plans*Please refer to our documentation on rate plans to choose a plan: View Amateur Rate Plans (PDF)Plan A01Plan A02Plan A03Plan A04Plan A05Plan A06Plan A07Plan A08Plan A09Plan A10Plan A11Plan A12Plan A13Plan A14Plan A15Plan A16Plan A17Plan A18Plan A19Plan A20Plan A21Plan A22Plan A23Plan A24Plan A25Plan A26Plan A27Plan A28Plan A29Plan A30Plan A31Plan A32Plan A33Plan A34Plan A35Plan A36Plan A37Plan A38Plan A39Plan A40Plan A41Plan A42Plan A43Plan A44Plan A45Plan A46Plan A47Plan A48Plan A49Plan A50Plan A51Plan A52Plan A53Plan A54Plan A55Plan A56Plan A57Plan A58Plan A59Professional Rate Plans*Please refer to our documentation on rate plans to choose a plan: View Professional Rate Plans (PDF)Plan P01Plan P02Plan P03Plan P04Plan P05Plan P06Plan P07Plan P08Plan P09Plan P10Plan P11Plan P12Plan P13Plan P14Plan P15Plan P16Plan P17Plan P18Plan P19Plan P20Plan P21Plan P22Plan P23Plan P24Plan P25Plan P26Plan P27Plan P28Plan P29Plan P30Plan P31Plan P32Plan P33Plan P34Plan P35Plan P36Plan P37Plan P38Plan P39Plan P40Plan P41Plan P42Plan P43Plan P44Plan P45Plan P46Plan P47Plan P48Plan P49Plan P50Plan P51Plan P52Plan P53Plan P54Plan P55Plan P56Plan P57Plan P58Plan P59Amateur / Professional Rate Plans*Please refer to our documentation on rate plans to choose a plan: View Professional Rate Plans (PDF)Plan P01Plan P02Plan P03Plan P04Plan P05Plan P06Plan P07Plan P08Plan P09Plan P10Plan P11Plan P12Plan P13Plan P14Plan P15Plan P16Plan P17Plan P18Plan P19Plan P20Plan P21Plan P22Plan P23Plan P24Plan P25Plan P26Plan P27Plan P28Plan P29Plan P30Plan P31Plan P32Plan P33Plan P34Plan P35Plan P36Plan P37Plan P38Plan P39Plan P40Plan P41Plan P42Plan P43Plan P44Plan P45Plan P46Plan P47Plan P48Plan P49Plan P50Plan P51Plan P52Plan P53Plan P54Plan P55Plan P56Plan P57Plan P58Plan P59Limitations*With LimitationsHospital 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 InformationHow 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 OptionsPayment*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 ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.
