1Contact & Event Information2Insurance Information3Additional Insured & Digital Signature Policyholder InformationName of Policyholder*The name of the business/organization purchasing the insurance; as it will appear on the policy documents and/or other contract or rental agreements. Mailing 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 Name* First Last Phone*Email* Organization / Event Website Event DetailsName of Event* Event Type* Desired coverage date (including setup and tear down):Start Date* MM slash DD slash YYYY toEnd Date* MM slash DD slash YYYY Estimated Gross Reciepts* Description of Event*Please provide a detailed list of all activities to be held or what will take place for the duration of your event to ensure your event is quoted properly and returned promptly. Please select one of the following:* I would like to purchase an Accident & General Liability Policy (i.e. includes Participant Liability which covers claims and medical bills of an injured athletic participant) I would like to purchase a Spectator / Premise Only policy (i.e. Provides General Liability coverage for use premise and against claims made by spectators. Claims made by ATHLETIC PARTICIPANTS are EXCLUDED.) Insurance DetailsEvent Level*AmatuerCollegeSemi-ProfessionalProfessionalSport Acitivity*List the sport(s) to be covered at the event. Total number of YOUTH Participants*18 and under.Please enter a number less than or equal to 1000.Total number of ADULT Participants*19 and up.Please enter a number less than or equal to 1000.If this is a tournament, total number of teams:Please enter a number less than or equal to 300.Estimated Number of Spectators Per DayPlease enter a number less than or equal to 1000.If activity is a race type activity, please provide distances for each race activity: Does race include obstacles? Yes No If yes, a full list of the obstacles will be required before a quote will be released. Please upload description of obstacles here or email to: Caitlyn@AnthonyInsuranceServices.comDoes your event have participants staying overnight?* Yes No Please DescribeEvent Location 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 If more than one location, please provide additional locations here:Do you utilize a waiver system?*Click here if you need a copy of a waiver. Yes No Do you have a Risk Management Plan?*If you do not yet have such a plan in place, please click here for our Guide to Risk Management. Yes No Has prior coverage been cancelled or non-renewed?* Yes No Please DescribeLiability Insurance Limit Requested* $1 Million $2 Million $3 Million $4 Million $5 Million Accident Medical Limits Requested*A minimum accident limit of $10,000 is required if participant liability coverage is desired. None $10,000.00 $25,000.00 $50,000.00 $100,000.00 Additional InsuredAdditional Insured 1 Name 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 Relationship Additional Insured 2 Name 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 Relationship Additional Information & Digital SignatureHow 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* CommentsThis field is for validation purposes and should be left unchanged. Δ
