Mixed Martial Arts Kickboxing Boxing Wrestling Toughman Online Application Form

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

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

Address of Policyholder/Promoter:

Street A value is required. City A value is required. State Please select an item. Zip Code A value is required.Invalid format.

Phone Number A value is required.Invalid format. Email Address A value is required.Invalid format.

Billing Address for Payment Info:

Street A value is required. City A value is required. State Please select an item. Zip Code A value is required.

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

Date Of Event A value is required.Please enter a date or click the button and select a date. Event Time Please select an item.

Event Name A value is required.

Fight Location Name (Venue) A value is required.

Fight Location Address: Street A value is required. City A value is required. State Please select an item. Zip Code A value is required.Invalid format.

Do You Want Accident Medical Coverage Only? Please select an item.

General Liability

Spectator Liability Limit:
2,000,000.00 Aggregate/1,000,000.00 Per Occurrence 1,000,000.00 Aggregate/1,000,000.00 Per Occurrence
Other Please make a selection. (If You Selected Other Option Please Write In Amount Here):

Security provider for the event A value is required.

Seating Capacity A value is required. Estimated Attendance A value is required.

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

1. Name Street City State Zip Code Invalid format.

2. Name Street City State Zip Code Invalid format.

3. Name Street City State Zip Code Invalid format.

Participant Accident Medical Program

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

Fight Total Pro: Invalid format. Fight Total Amateur: Invalid format.

Comprehensive Benefit Option Limited Benefit Option Please make a selection.

Accident Medical Coverage: Please select an item. Accidental Death & Dismemberment Coverage: Please select an item.

Per Claim Deductible: Please select an item.

Policyholder Signature: A value is required. Title or Position A value is required. Date Signed A value is required.Please enter a date or click the button and select a date.

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

Payment Method

Credit Card Will Call With Card Info Please make a selection.

*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.