Insurance Form

Name of IKF/ISCF Promoter:__________________________________________ Where is event to be held: ______________________, ____________________ What is the DATE of your event: ____/____/____ Is the event ___IKF Sanctioned, ___ISCF Sanctioned or ____Both? Are you requesting Venue Liability for your event for $1 Million Coverage at the fee of $450.00? _____ Yes _____No Are you requesting Fighter Medical Insurance from one of the rate packages below? _____ Yes _____No If so, which "PLAN NUMBER BELOW" are you requesting: ________
Plan Number	Maximum Medical Benefit	Accidental Death Benefit	Deductible	Premium Rates
$2,500.00 - $2,500.00
1	$2,500.00	$2,500.00	$2,000.00	$350.00
2	$2,500.00	$2,500.00	$1,500.00	$450.00
3	$2,500.00	$2,500.00	$1,000.00	$495.00
4	$2,500.00	$2,500.00	$500.00	$540.00
$5,000.00 - $5,000.00
5	$5,000.00	$5,000.00	$1,500.00	$540.00
6	$5,000.00	$5,000.00	$1,000.00	$585.00
7	$5,000.00	$5,000.00	$500.00	$630.00
$7,500.00 - $7,500.00
8	$7,500.00	$7,500.00	$2,000.00	$440.00
9	$7,500.00	$7,500.00	$1,500.00	$640.00
10	$7,500.00	$7,500.00	$1,000.00	$700.00
11	$7,500.00	$7,500.00	$500.00	$755.00
$10,000.00 - $10,000.00
12	$10,000.00	$10,000.00	$2,500.00	$565.00
13	$10,000.00	$10,000.00	$2,000.00	$630.00
14	$10,000.00	$10,000.00	$1,500.00	$720.00
15	$10,000.00	$10,000.00	$1,000.00	$775.00
16	$10,000.00	$10,000.00	$500.00	$880.00
$20,000.00 - $20,000.00
17	$20,000.00	$20,000.00	$5,000.00	$445.00
18	$20,000.00	$20,000.00	$2,500.00	$690.00
19	$20,000.00	$20,000.00	$2,000.00	$775.00
20	$20,000.00	$20,000.00	$1,500.00	$855.00
21	$20,000.00	$20,000.00	$1,000.00	$1,160.00
22	$20,000.00	$20,000.00	$500.00	$1,290.00
$20,000.00 - $50,000.00
23	$20,000.00	$50,000.00	$5,000.00	$580.00
24	$20,000.00	$50,000.00	$2,500.00	$845.00
25	$20,000.00	$50,000.00	$2,000.00	$915.00
26	$20,000.00	$50,000.00	$1,500.00	$1,060.00
27	$20,000.00	$50,000.00	$1,000.00	$1,170.00
28	$20,000.00	$50,000.00	$500.00	$1,440.00
$25,000.00 - $20,000.00
29	$25,000.00	$20,000.00	$5,000.00	$510.00
30	$25,000.00	$20,000.00	$2,500.00	$900.00
31	$25,000.00	$20,000.00	$2,000.00	$1,000.00
32	$25,000.00	$20,000.00	$1,500.00	$1,125.00
33	$25,000.00	$20,000.00	$1,000.00	$1,250.00
34	$25,000.00	$20,000.00	$500.00	$1,350.00
$250,000.00 - $25,000.00
35	$25,000.00	$25,000.00	$5,000.00	$675.00
36	$25,000.00	$25,000.00	$2,500.00	$880.00
37	$25,000.00	$25,000.00	$2,000.00	$960.00
38	$25,000.00	$25,000.00	$1,500.00	$1,070.00
39	$25,000.00	$25,000.00	$1,000.00	$1,090.00
40	$25,000.00	$25,000.00	$500.00	$1,385.00
$50,000.00 - $50,000.00
41	$50,000.00	$50,000.00	$5,000.00	$935.00
42	$50,000.00	$50,000.00	$2,500.00	$1,530.00
43	$50,000.00	$50,000.00	$2,000.00	$1,725.00
44	$50,000.00	$50,000.00	$1,500.00	$1,890.00
45	$50,000.00	$50,000.00	$1,000.00	$1,995.00
46	$50,000.00	$50,000.00	$500.00	$2,160.00
$50,000.00 - $100,000.00
47	$50,000.00	$100,000.00	$5,000.00	$1,070.00
48	$50,000.00	$100,000.00	$2,500.00	$1.635.00
49	$50,000.00	$100,000.00	$2,000.00	$1,935.00
50	$50,000.00	$100,000.00	$1,500.00	$2,130.00
51	$50,000.00	$100,000.00	$1,000.00	$2,320.00
52	$50,000.00	$100,000.00	$500.00	$5,580.00
$100,000.00 - $100,000.00
53	$100,000.00	$100,000.00	$5,000.00	$2,600.00
54	$100,000.00	$100,000.00	$2,500.00	$3,105.00
55	$100,000.00	$100,000.00	$2,000.00	$3,345.00
56	$100,000.00	$100,000.00	$1,500.00	$3,915.00
57	$100,000.00	$100,000.00	$1,000.00	$4,680.00
58	$100,000.00	$100,000.00	$500.00	$6,300.00


PLAN NUMBER	Maximum Medical Benefit	Accidental Death Benefit	Deductible	Rates
1	$2,500.00	$2,500.00	$2,000.00	$460.00
2	$2,500.00	$2,500.00	$1,500.00	$590.00
3	$2,500.00	$2,500.00	$1,000.00	$700.00
4	$2,500.00	$2,500.00	$500.00	$770.00

5	$5,000.00	$5,000.00	$1,500.00	$790.00
6	$5,000.00	$5,000.00	$1,000.00	$840.00
7	$5,000.00	$5,000.00	$500.00	$910.00

8	$10,000.00	$10,000.00	$2,000.00	$880.00
9	$10,000.00	$10,000.00	$1,500.00	$1,100.00
10	$10,000.00	$10,000.00	$1,000.00	$1,190.00
11	$10,000.00	$10,000.00	$500.00	$1,400.00

12	$15,000.00	$15,000.00	$1,000.00	$1,490.00
13	$15,000.00	$15,000.00	$500.00	$1,800.00

14	$20,000.00	$20,000.00	$2,000.00	$1,300.00
15	$20,000.00	$20,000.00	$1,500.00	$1,900.00
16	$20,000.00	$20,000.00	$1,000.00	$2,400.00
17	$20,000.00	$20,000.00	$500.00	$2,750.00

18	$25,000.00	$25,000.00	$5,000.00	$800.00
19	$25,000.00	$25,000.00	$2,500.00	$1,880.00
20	$25,000.00	$25,000.00	$2,000.00	$2,050.00
21	$25,000.00	$25,000.00	$1,500.00	$2,280.00
22	$25,000.00	$25,000.00	$1,000.00	$2,570.00
23	$25,000.00	$25,000.00	$500.00	$2,900.00

24	$50,000.00	$50,000.00	$5,000.00	$920.00
25	$50,000.00	$50,000.00	$2,500.00	$2,900.00
26	$50,000.00	$50,000.00	$2,000.00	$3,460.00
27	$50,000.00	$50,000.00	$1,500.00	$3,750.00
28	$50,000.00	$50,000.00	$1,000.00	$4,000.00
29	$50,000.00	$50,000.00	$500.00	$4,250.00

30	$100,000.00	$100,000.00	$5,000.00	$3,870.00
31	$100,000.00	$100,000.00	$2,500.00	$4,620.00
32	$100,000.00	$100,000.00	$2,000.00	$5,120.00
33	$100,000.00	$100,000.00	$1,500.00	$5,590.00
34	$100,000.00	$100,000.00	$1,000.00	$5,900.00
35	$100,000.00	$100,000.00	$500.00	$7,700.00