Mixed Martial Arts Insurance, Boxing Events Accident Insurance

Policy Holder Information

Full 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 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

Liability Questionnaire

Seating 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 Limits

Rates are limited to events with 2,000 or less attendance. Quotations available for larger events. Please contact our office.

Limit Per Occurrence

Higher 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

Liability Sub Total:*

Additional Insureds and Optional Coverages

Optional 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.

Hired and Non-Owned Automobile Liability Coverage Price

Medical Expense Benefit

Medical Expense Benefit Price

Price: $0.00

Additional Insured

3 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.

Name	Street Address	City	State	Zip	Comments

Total Premium

$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:

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

Email

This field is for validation purposes and should be left unchanged.