National Provider of Sports & Entertainment Insurance


13100 Shire Lane    Fort Myers, FL    33912

 (888) 288-1829 tel (630) 393-5666 fax



Boxing / Mixed Martial Arts Events Liability Insurance Program Application


Liability Insurance

Name of Policyholder/Promoter  


   Fax 999-999-9999

Street Address  
City    State    Zip Code  
Phone    999-999-9999
Is Policyholder    If Other, explain
Name & Location of Event  
Date & Time(s)    Seating Capacity   Estimated Attendance

Liability Insurance Limits Requested

$1,000,000.00 Per Occurrence / $1,000,000.00 General Aggregate

          Premium Cost $722.25 (Insureds Located in New York)

          Premium Cost $695.20 (Insureds Located in AZ, CA, CT, FL, KY, NV, PA, SC and TX

          Premium Cost $590.00 (Insureds Located in MS, RI and NJ

          Premium Cost $535.00 (Insureds Located in All Other States)

Higher General Aggregate are available for an additional 5% per $1,000,000, up to $5,000,000.

Has any of the Policyholder's/ Promoter's past boxing insurance policies been cancelled or non-renewed?


If Yes, please give details.

Has any of the Policyholder's/ Promoter's past boxing insurance policies had claims filed against them?  

If Yes, please give details.

Is the Policyholder/Promoter responsible for any of the following?

Temporary Lighting

Temporary Stage







  Security Provider for the event:

Fire Protection:  Proximity to Fire/Medical Services

                        Is Facility Protected by Sprinkler System?   

                        Are Fire Extinguishers Located at Facility?   

List any Additional Insured and relation to the applicant:

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


Authorized Electronic Signature:
Title or Position:





DHC is a USA company and can not provide coverage outside of the USA.

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13100 Shire Lane   |   Fort Myers, FL   |   33912   |  (888) 288-1829 tel   (630) 393-5666 fax

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