National Provider of Sports & Entertainment Insurance


13100 Shire Lane    Fort Myers, FL    33912

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



Boxing, Kickboxing, Mixed Martial Arts, Wrestling and Toughman Accident Medical Insurance

Request for Quotation

Please complete the following information. Once this request is received, a quotation will be sent within one business day. As sports and recreation activities vary, some questions may not be applicable. Please indicate "N/A" where necessary. 

* = required field

Name of Event or Promoter*  
Contact Name*  


   Fax 999-999-9999

Street Address*  
City*    State*          Zip Code* 
Phone*    999-999-9999
How do you wish to receive your Quotation?* Email  Fax   Mail
Date of Event.*  


 Boxing  Kickboxing  Mixed Martial Arts  Wrestling  Toughman

Number of Bouts*

Requested Accident Medical Limit*   
Requested Accidental Death & Dismemberment Limit*  

Requested Deductible Amount*



The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer.


The undersigned acknowledges and agrees that the submission and the insurer's receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage.


It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies.


Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information on 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 applicable until accepted by DHC Insurance, L.L.C.

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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