Coverage Information

JavaScript is disabled in your browser. Please note that some features of our site require JavaScript.
Click here for instructions on how to enable JavaScript.

There were errors with this submission. Please correct the errors below and resubmit.

Fields marked with an asterisk (*) are required.

Please select your coverage term:

Annual (Coverage for your Box)

Short-Term (Coverage for your Throwdown or Event)

First Date of Coverage (12 months of coverage is provided):

Last Date of Coverage:

Total number of Athletes participating at all Box Locations:

Optional Coverages

Please select an option for Liability Coverage. Minimum premiums are fully earned.

No Liability Coverage

$1,000,000 Per Occurrence / $1,000,000 General Aggregate
Cost: $2.10 per participant (Minimum Premium $260.00)

$1,000,000 Per Occurrence / $2,000,000 General Aggregate
Cost: $2.21 per participant (Minimum Premium $273.00)

$1,000,000 Per Occurrence / $3,000,000 General Aggregate
Cost: $2.32 per participant (Minimum Premium $287.00)

$1,000,000 Per Occurrence / $4,000,000 General Aggregate
Cost: $2.43 per participant (Minimum Premium $301.00)

$1,000,000 Per Occurrence / $5,000,000 General Aggregate
Cost: $2.55 per participant (Minimum Premium $316.00)

Policyholder

Full Legal Name of Your Box:	*
Note: This is the name that will appear on your Certificate of Insurance.

Have you had any accident insurance claims in the last 3 years? * Yes No

Contact Information

Contact First Name:	*	Contact Last Name:	*
Phone Number 1:	*	Phone Number 2:	*
Fax Number:	*
Email Address:	*	Confirm Email:	*

Mailing Address

Mailing Address 1:	*	Mailing Address 2:	*
City:	*
State:	*
Zip Code:	*

My Box Address

My Box Location is the same as my Mailing Address above. * Yes No

I would like to add additional Locations for my Box. * Yes No

For Questions: Affiliate Guard
801-688-4883
vaughn@affiliateguard.info