DHC Insurance, LLC - Sports insurance, Sports team liability insurance, youth sports accident insurance

National Provider of Sports & Entertainment Insurance

PO BOX 948 Warrenville, IL 60555

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

Annual Outdoorsman's Insurance Program Application

* = required field

Name *

Email*

Fax 999-999-9999

Street Address*

City*    State*    Zip Code*

Phone*    999-999-9999

Date of Birth* (MM/DD/YYYY)

Effective Date of Coverage*    (MM/DD/YYYY)

Termination Date of Coverage* (MM/YYYY)

Name of Beneficiary*

Relationship to Insured*

Plan of Benefits

Plan (select)
Benefits Premium

Plan 1

$50,000.00 Death & Dismemberment
$5,000.00 Accident Medical Expense
$99.00

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. Minimum premiums are fully earned.

Authorized Electronic Signature*:

Title or Position:

PO BOX 948 | Warrenville, IL | 60555 | (888) 288-1829 tel (630) 393-5666 fax

Wheaton Web Designs