| *Required |
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| Company
Information |
Paper Version |
| Company
Name |
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| First
Name* |
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| Last
Name* |
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| Address* |
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| City* |
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| State* |
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| Zip* |
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| Daytime
Telephone Number* |
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| Mobile
Telephone Number |
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| Fax
Number |
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| Your
Email Address* |
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| Your
Website Address |
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| Years
Experience* |
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| Who,
if anyone, referred you to us?* |
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| For
Insurance Agents & Brokers Only: Brokers Name |
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| General
Information
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| Title
of Production* |
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Type
of Production*(Commercial,
Short, SAG Experimental, Feature, etc.) |
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| Shoot
Date(s)* |
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| Shoot
Times* |
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| Desired
Effective Date of Policy* |
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| Desired
Expiration Date of Policy* |
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| Detailed
Description of Production* |
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| Budget:
$ * |
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| Total
Number of Shoot Days* |
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| Number
of Cast* |
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Number of Crew* |
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| Number
of Others (Bystanders, Extras, etc.)* |
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| Location
Information |
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| Name
of Location* |
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| Mailing
Address |
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| City* |
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| State* |
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| Zip |
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| Telephone
Number |
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| Fax
Number |
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| Contact
Person (First & Last Name) |
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| Contact
Person Email Address |
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| Location
Additional Insured Wording (Found in your rental agreement) |
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| Who
is supplying security?* |
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| Is
security armed?* |
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| Underwriting
Information |
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| List
anyone else you need to name as Additional Insured on your
policy |
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| Describe
First Aid/Medical arrangements* |
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| Will
shoot include any Stunts, Pyrotechnics, Aircraft, pools,
lakes or other bodies of water, Car Races, Rides or other
Hazardous Activities?* |
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| If
yes, please explain |
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| Who
was your previous insurance company* |
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| Premium
paid: $* |
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| List
all previous claims (Last 5 years)* |
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Would
you like an annual quote insuring all of the productions
you have planned for the next 12 months? If
yes, you must complete and submit a schedule
of the shoots you want insured. |
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Non-Owned
& Hired Auto Option
Consider
this option if your employees are using their vehicles
on company business or you're renting/borrowing vehicles.
You also have the option to insure against physical damage
to the rented/hired vehicles.
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| Number
of vehicles rented or borrowed? |
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| Number
of vehicles used by employees? |
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| Total
cost to rent vehicles: |
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| If
physical damage to rented vehicles is desired, what is the
maximum value of any one vehicle? |
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| What
is the total value of all vehicles? |
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Property,
Negative & Faulty, 3rd Party Property Option
Negative/Faulty
covers you for damage to negatives, for faulty stock &
for faulty cameras. Extra Expense reimburses you for out-of-pocket
expenses as a result of damage to equipment. 3rd Party
covers damage to locations.
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| Description
of Equipment |
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| Describe
protection, security at principal location |
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| Value
of Owned Equipment: $ |
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| Value
of Rented Equipment: $ |
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| Value
of Sets, Props & Wardrobe: $ |
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| Total
Values: $ |
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| Include
Negative, Faulty Stock & Camera Processing coverage? |
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| Include
Extra Expense? |
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| Include
3rd Party Property Damage? |
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Workers'
Compensation Option
Usually
required by state law for employers who have 1 or more
employees. Premium is based on payroll for the period
of time the policy is in force. Owners / officers are
excluded from coverage.
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| Number
of Full Time Employees |
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| Number
of Part Time Employees |
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| Total
Payroll (W-2, 1099, Deferred and other payroll) |
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| Payroll
Company (if any) |
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| Full
names and titles of all owners or officers. Coverage will
be excluded for these persons. |
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| Employers'
Federal I.D. Number |
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Weather
Insurance Option
If
your production would be affected by bad weather, consider
buying Rain / Snow / Wind / Lightning coverage
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| Coverage
Date |
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| Coverage
Times |
From
To
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| Policy
Limit: $ |
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| Include
the following perils |
Rain:
Lightning:
Snow:
Wind:
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| List
any additional dates and times in the Additional Notes section
below |
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Production
Cancellation Insurance Option
Broader
than Weather Insurance, it can cover cancellation due
to damage to the location, terrorism, non-appearance of
an actor, etc.With the information below, we will be able
to give you a general idea on pricing. However, for a
firm quote, a more detailed application will be required.
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| Is
the shoot indoors? |
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| If
no, is the filming area under a cover? |
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| Would
bad weather cause cancellation of your shoot? |
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| List
the Actors or other key persons and their ages whose non-appearance
would cause a delay in the production |
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| Application
Notes/Additional Information |
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Application
Warranty & Instructions
I
HEREBY WARRANT AND CONFIRM THAT THE ABOVE INFORMATION,
TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, AND
FURTHER CERTIFY THAT I HAVE READ ALL OF THE QUESTIONS
AND ANSWERS OF THIS APPLICATION. I UNDERSTAND THIS APPLICATION
IS A REQUIREMENT FOR COVERAGE, A PART OF THE CONTRACT
AND EVIDENCE OF MY ACCEPTANCE OF THIS INSURANCE, AND ANY
FALSIFICATION OR MISREPRESENTATION WILL BE DEEMED A BREACH
OF CONTRACT, VOIDING ALL INSURANCE COVERAGE. IT IS UNDERSTOOD
AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL
NOT BE BINDING EITHER TO THE PROPOSED INSURED OR THE COMPANY
UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.
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| Name
of person acknowledging Warranty* |
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| Date
of acknowledgment* |
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| For
Insurance Agents & Brokers Only |
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| Your
Company Name |
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| First
Name |
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| Last
Name |
|
|
| Address |
|
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| City |
|
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| State |
|
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| Zip |
|
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| Daytime
Telephone Number |
|
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| Mobile
Telephone Number |
|
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| Fax
Number |
|
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| Your
Email Address |
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