Property Insurance Application

*Required
Company Information			Paper Version
Company Name
First Name*
Last Name*
Address*
City*
State*
Zip*
Daytime Telephone Number*
Mobile Telephone Number
Fax Number
Your Email Address*
Your Website Address
Years Experience*
General Information
Type of Business*(Sound & Light, Post Production House, Artist, etc.)
Desired Effective Date of Policy*
Desired Expiration Date of Policy*
Principal Storage Location Address*
City*
State*
Zip
Describe Protection (Central Station Alarm, Dead Bolts, etc.)*
Who was your previous insurance company*
Premium paid:*
List all previous claims (Last 5 years)*
Policy Limits Please list your replacement cost property values scheduled as follows
Editing & Post-Production Equipment (Film & Video, Computer Generated Special Effects, Audio Sweetening, Animation, etc.)
Recording & Studio Equipment (In Studio Equipment)
Sound Recording Equipment (On Location, In Transit)
Musical Instruments & Band Equipment (In Studio & On Location, In Transit)
Camera & Production Equipment (Still, Video & Motion Picture Cameras, Grip, Lighting, Lenses & Related Equipment. In Studio and On Location)
Sound & P.A. Equipment (Sound Amplification / Reinforcement)
Office Contents
Rented Equipment (Maximum Value of Equipment You Rent or Borrow From Others)
Miscellaneous Unscheduled Equipment (Total Value of your equipment valued less than $500 per item - $10,000 Maximum allowed)
Total Policy Limit:
Rental Reimbursement pays to rent substitute equipment in case of a loss. Would you like a quote on this option?
If yes, what would it cost you PER DAY to rent replacement equipment?
Schedule of Insured Items List all items valued $500 or more that you wish insured. Any item you don't list is excluded. Please include the Manufacturer, Model #, Serial # if valued at more than $10,000, Description, and Replacement Cost Value Example: Fender - Highway 1 Stratocaster - Guitar - $1,000.
Application Notes/Additional Information
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.
Name of person acknowledging Warranty*
Date of acknowledgment*
For Insurance Agents & Brokers Only
Your Company Name
First Name
Last Name
Address
City
State
Zip
Daytime Telephone Number
Mobile Telephone Number
Fax Number
Your Email Address