Sport Event Insurance Application

* = required field

Applicant Information

Contact Name*
Entity/Organization*
Mailing Address*
City*
State*
Zip Code*
Phone*	-- 999-999-9999
Fax	-- 999-999-9999
Contact Email*
Website

Event Details

Name of Event*
Type of Event*
Desired Effective Start Date*
Desired Expiration Date*
Description of Event*
What is the seating capacity of the event?*
Estimated spectator attendance per day*
Total Number of Days*
Estimated Gross Receipts*
Would you like to purchase spectator/premise only coverage?*	Yes No
Would you like to purchase accident and liability insurance?*	Yes No If Yes, please complete the Insurance Details section.

Insurance Details

Event Level*

Sport / Activity to be covered	# Youth Participants	# Adult Participants	# Coaches / Instructors	If Tournament, # of Teams	# Days

If the activity or sport to be covered is a race (i.e. running race, triathlon, cycling race, etc.), please provide the distance(s) the race participants can register for:
Does the event have participants overnight?*	Yes No
If Yes, please describe
Location of Event*
Address*
City*
State*
Zip Code*
If more than one location, please provide additional locations

Do you use a waiver system?*	Yes No Click here if you need a copy of a waiver.
Has prior coverage been cancelled or non-renewed?*	Yes No
If Yes, please describe
Do you have a Risk Management Plan?*	Yes No
Liability Insurance Limit Requested*	$1 Million $2 Million $3 Million $4 Million $5 Million
Accident Medical Limits Requested*	$10,000.00 $25,000.00 $50,000.00 $100,000.00
Select accident medical deductible (Check option(s) you would like included in your quote)	$100 $250 $500 $1,000 $2,500

Additional Insured

Additional Insured 1
Name:
Address:
City:
State:
Zip:
Relationship

Additional Insured 2
Name:
Address:
City:
State:
Zip:
Relationship:

To add additional insured(s) to your policy, please complete and submit the Add Additional Insured to My Existing Policy form.

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.
Authorized Electronic Signature*:
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