Film Insurance Application Step 1 of 5 20% Policyholder InformationYour Company NameThe company name on the policy should be the same legal entity signing the permits/location contracts, if any.----------This is NOT the place to put the name of your production. You will be asked for that information on the next screen.----------Insurance Brokers- DO NOT put your name here. You will be asked for that information on the next screen. Your Full Name*Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone Number (Preferably Mobile)*Can this phone accept texts?YesNoClick Yes if you would like reminder texts about your quote & policy.Secondary Phone NumberCan this phone accept texts?YesNoEmail (If you are an insurance broker, use your email & not your clients)* Enter Email Confirm Email obsolete 8-20-19 WebsiteHow many years of experience do you have?*Who referred you to us?Are you a Non-Profit Corporation?YesNoAre you an insurance agent/broker applying for a quote on behalf of your client?*YesNoFor Insurance Agents & Brokers OnlyYour Insurance Agency NameRemember to enter YOUR email address above, NOT your client's email. Otherwise they will receive automatic notifications and our quote instead of you.Agents First NameAgents Last NameAddress Mailing Address City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe TelephoneFaxRemember to enter your email address on the previous screen in lieu of your client's email. Or, Save what You've Entered So Far and Continue Later Film DetailsName of Production*Type of Production*Shoot Dates*Policy start date* Date Format: MM slash DD slash YYYY This should be the first date you set up or pick up equipment or otherwise need your policy to start.Policy end date* Date Format: MM slash DD slash YYYY This should be the last day you will be on set, or the last day you will have rented equipment or the last day you would otherwise need your policy.Detailed description of production*Production Budget*Maximum number of persons on set each day* Or, Save what You've Entered So Far and Continue Later LocationsProvide details on all shoot locations*You can upload a copy of your rental agreement below.Do any of your contracts require a Primary & Noncontributory endorsement?*Higher rates apply if you need it.YesNoDo any of your contracts require a Waiver of Subrogation endorsement?*Higher rates apply if you need it.YesNoWhat Per Occurrence limit do you need us to quote? found in your location contracts)*What Aggregate limit do you need us to quote? (found in your location contracts)*List anyone you need to name as Additional insuredExtra premium will apply to anyone other than sites/locations.Who is supplying security*Is security armed?*YesNoUpload any contract, synopsis, budget, etc. you want us to see.Acceptable file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. Maximum File Size: 128MB. Drop files here or Accepted file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. Or, Save what You've Entered So Far and Continue Later Additional InformationProvide details on any stunts, pyrotechnics, aircraft, drones, bodies of water, car races or any other hazardous activity*Your previous Insurance company*Premium PaidList any previous claims*Upload a copy of your event flyer or advertisement (Unless your website shows your ad).Acceptable file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. Maximum File Size: 128MB. Drop files here or Accepted file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. Any additional information we need to know? Or, Save what You've Entered So Far and Continue Later Options That Can Be Added To your PolicyAdditional premium will apply. Would you like a quote for Rented/Borrowed Auto Liability?*YesNoNumber of vehicles you will rent or borrow?*Your cost to rent the vehicles?*Are all drivers at least 25 years old?*Any vehicles seat more than 12 persons?*What will the vehicles be used for?*Would you like a quote for Rented &/or Owned Equipment?*YesNoDescription of all equipment*Describe protection / security at principal location*Total Value of Rented Equipment/Sets/Props/Contents?*Total value of Owned equipment/Sets/Props/Contents?*Date rented equipment is being picked up* Date Format: MM slash DD slash YYYY Date the last of the equipment is returned* Date Format: MM slash DD slash YYYY Would you like a quote for Workers' Compensation?*YesNoNumber of workers*Payroll*Do not put annual payroll here unless you are requesting an annual quote. Only put the payroll for the duration of your event (including set-up and tear-down).You must also include the amount you are paying subcontractors unless they have their own workers' compensation insurance. You will need to keep on file their certificate of insurance if they tell you they have a policy.Describe workers' duties*Your Federal I.D. Number*Name & Title of an owner or corporate officer*You and all other owners, officers and directors of the company will be excluded from coverage.Social Security Number*Would you like a quote for Volunteer / Staff / Performer Accident Medical?*This coverage is not a substitution for workers' compensation insurance. See above. YesNoNumber of Daily volunteers?*Number of Daily staff?*Number of Daily Performers?*Describe what duties the volunteers will have*Would you like a quote for Rain (Weather) Insurance?*YesNoCoverage Date(s)*Policy Limit*Coverage Time Begins*Coverage Time Ends*Would you like a quote for Event Cancellation/Non-Appearance Insurance?*YesNoFor outdoor events, is the performance area under a cover/roof? Explain.*Budgeted Total Gross Receipts?*NameThis field is for validation purposes and should be left unchanged. Or, Save what You've Entered So Far and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.