Policy Holder InformationFull Legal Name*Enter in the business entity name or name of individual purchasing policy. This is typically the same name as what is listed on the rental agreement with the venue of event. Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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* MM slash DD slash YYYY Location of the Event* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Select if event is Amateur or Professional:* Amateur Professional Combined (Amateur and Professional) Select the event type:* Mixed Martial Arts Kickboxing Boxing Wrestling Liability QuestionnaireSeating Capacity*Estimated Attendance*Have any of the Policyholder’s/Promoter’s past boxing insurance policies been cancelled or non-renewed in the past?* Yes No Have any of the Policyholder’s/Promoter’s past boxing insurance policies had claims filed against them?* Yes No Is the Policyholder/Promoter responsible for any of the following?* Temporary Lighting Tent Security Vendors Temporary Stage Ushers Liquor Concessions None Security Provider for the Event* Proximity to Fire/Medical Services (miles)*Is Facility Protected By Sprinkler System?* Yes No Are Fire Extinguishers Located at Facility?* Yes No Liability LimitsRates are limited to events with 2,000 or less attendance. Quotations available for larger events. Please contact our office.Limit Per Occurrence$1,000,000.00Higher per occurrence limits of up to $4,000,000.00 are available but subject to additional underwriting. Please contact your agent if wishing to apply for coverage.Aggregate Limit$1,000,000.00$2,000,000.00$3,000,000.00$4,000,000.00$5,000,000.00Liability Sub Total:*Additional Insureds and Optional CoveragesOptional Coverages (Premiums are fully earned at inception)Hired and Non-Owned Automobile Liability Coverage$1,000,000.00 Hired and Non-Owned Automobile Liability Coverage is available but subject to additional underwriting. Please contact your agent if wishing to apply for coverage.None$150,000.00$500,000.00Hired and Non-Owned Automobile Liability Coverage PriceMedical Expense BenefitNone$5,000.00Medical Expense Benefit Price Price: $0.00 Additional Insured3 additional insureds can be added at no charge. Any additional insured over 3 will cost an additional $10 per insured. Please call our office to add additional insured over 3.NameStreet AddressCityStateZipComments Total Premium $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: Administration Fee: A $10 administration fee is added to all policy premium payments. Total Due Today $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged. Δ
