MMA, Kickboxing, Boxing, Wrestling, & Toughman Application Form

Name of Policyholder/Promoter A value is required.  Please select an item.

Address of Policyholder/Promoter:

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Billing Address for Payment Info:

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Event Type: MMA Kickboxing Boxing Wrestling Toughman Minimum number of selections not met. (check all that apply)

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General Liability

Spectator Liability Limit:

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Additional Insured’s for General Liability (Name and Address):

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Participant Accident Medical Program

Event Classification:   Minimum number of selections not met. (check all that apply)

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Place any other questions, comments or any additional info that you wish to submit in the box below:

Payment Method

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*A payment/processing/application fee will be applied, however, the amount can’t be determined until the application is reviewed and finalized.

Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits application or files claim containing a false or deceptive statement may be guilty of insurance fraud.

By placing your name in the policyholder signature box and clicking the submit button you are agreeing that this will serve as your electronic signature and also authorize the policy(s) premium to be charged to the credit card provided.

Clicking the button will let you review your information before the form is submitted.