Business DetailsName of Group* Name of Organizer First Last Phone*Email* FaxAddress* Street Address Address Line 2 City State 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 ZIP Code Desired Effective Date of Coverage*All policy terms are Annual. MM slash DD slash YYYY What type of entity are you?*CorporationMunicipalityPartnershipHealth ClubPark DistrictIndividualLLCOtherWhat styles or genres are played? Please be specific.*Has your past liability coverage been cancelled in any way in the last three years?* Yes No please be specific:Premium Calculation*All policies are issued with a $1,000,000.00 occurrence limit. *Premium based on the number of youth participants and the number of adult participants multiplied the participant rate, per the aggregate limit selected. *Minimum Premium Applies. *All (100%) participants must be accounted for. Total Number of Youth Participants*Total Number of Adult Participants*Select A Plan:Plan* Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Aggregate Limit Rate per Youth Participant Rate per Adult Participant Minimum Premium $1,000,000.00 $4.99 $6.76 $450.00 $2,000,000.00 $5.20 $7.00 $465.00 $3,000,000.00 $5.39 $7.29 $480.00 $4,000,000.00 $5.59 $7.55 $495.00 $5,000,000.00 $5.79 $7.81 $510.00 Subtotal Policy Premium:Optional Coverage(s)Add Optional Hired and non-owned automobile liability coverage?This liability coverage provides protection for rented, borrowed and other non-owned vehicles driven on live action role playing business. (Not available in MA, NJ & NY) No $150,000 Limit ($225 premium) $500,000 Limit ($500 premium) $1,000,000 Limit ($850 premium and our receipt and approval of our Hired/Non-owned Auto supplemental application. Please contact me if you would like this application.) Optional Auto Coverage:Add $100,000 Sexual Abuse & Molestation Liability coverage?Liability coverage is provided for claims arising out of alleged sexual abuse and/or molestation. No Yes $1,000 premium Optional Abuse/Molestation Coverage:Additional Optional Coverage(s) **: (Please check any that you would like additional information and/or quotes.)Higher Sexual Abuse & Molestation Liability CoverageUp to $1,000,000.00 Equipment Coverage up to $750,000.00 - This Inland Marine insurance product provides coverage for your equipment and contents up to the specified limit. If you select this option, please also submit the Equipment Floater Application which will open in a new browser window. ** Note: The addition of any of these optional coverages will require further underwriting and impact the total policy premium. An agent will contact you shortly to provide the additional quotation(s).Plan 1 Attendee CalculationPlan 1 Attendee Adjustment Calculation Price: $0.00 Plan 2 Attendee CalculationPlan 2 Attendee Adjustment Calculation Price: $0.00 Plan 3 Attendee CalculationPlan 3 Attendee Adjustment Calculation Price: $0.00 Plan 4 Attendee CalculationPlan 4 Attendee Adjustment Calculation Price: $0.00 Plan 5 Attendee CalculationPlan 5 Attendee Adjustment Calculation Price: $0.00 Total Policy Price:Total Policy Premium Due Today: $0.00 Waiver RequirementDo you use a waiver?*If No, click here to download a waiver. Yes No Do you currently have a risk management plan?* Yes No Additional InsuredAditional Insured 1 Name Address Street Address City State 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 ZIP Code Relationship Aditional Insured 2 Name Address Street Address City State 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 ZIP Code Relationship 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.Authorized Electronic Signature:* Title or Position: Terms & ConditionsI have read and agree with the Terms & Conditions. Yes 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 $15.00. Administration Fee Amount Price: Administration Fee: A $15 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 Expiration Date Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name Δ
