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

Toughman Events Accident Medical Insurance Application

Accident Medical Insurance

Name of Policyholder/Promoter

Email

Fax 999-999-9999

Street Address

City    State Zip Code

Phone    999-999-9999

Date of Event

Plan of Benefits & Premium Rates (Select a Plan)

Plan Number Maximum Medical Benefit Accidental Death Benefit Deductible Premium

1 $2,500.00 $2,500.00 $500.00 $805.00

2 $5,000.00 $5,000.00 $500.00 $1,125.00

3 $10,000.00 $10,000.00 $500.00 $2,000.00

4 $20,000.00 $20,000.00 $500.00 $2,500.00

5 $50,000.00 $50,000.00 $500.00 $3,000.00

All above premium rates are per 2-day event

I understand and agree that if this application is accepted by the Company, coverage will begin on the date of acceptance or on the date requested in Date of Event (above), whichever is later, subject to the payment of the required premium.

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:

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

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