Name of Policyholder/Promoter
Email	Fax 999-999-9999
Street Address
City	State  AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip Code
Phone	999-999-9999
Is Policyholder	... A Corporation An Individual A Partnership Other   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?	... Yes No If Yes, please give details.
Has any of the Policyholder's/ Promoter's past boxing insurance policies had claims filed against them?	... Yes No If Yes, please give details.
Is the Policyholder/Promoter responsible for any of the following?	Temporary Lighting Temporary Stage	Tent Ushers	Security Liquor	Vendors Concessions
	Security Provider for the event:
	Fire Protection:  Proximity to Fire/Medical Services                         Is Facility Protected by Sprinkler System?    ... Yes No                         Are Fire Extinguishers Located at Facility?    ... Yes No

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: