*Required
 
Company Information
Paper Version
Company Name  
First Name*
Last Name*  
Address* (No P.O. Boxes)  
City*  
State*  
Zip*  
Daytime Telephone Number*  
Mobile Telephone Number  
Fax Number  

Your Email Address*

 
Your Website Address  
Years Experience*  
Who, if anyone, referred you to us?*  

For Insurance Agents & Brokers Only: Brokers Name

 
General Information
 
Title of Production*  

Type of Production*(Commercial, Short, SAG Experimental, Feature, etc.)

 
Shoot Date(s)*  
Shoot Times*  
Desired Effective Date of Policy*  
Desired Expiration Date of Policy*  
Detailed Description of Production*  
Budget: $ *  
Total Number of Shoot Days*  
Number of Cast*  
Number of Crew*  
Number of Others (Bystanders, Extras, etc.)*  
Location Information
 
Name of Location*  
Mailing Address  
City*  
State*  
Zip  
Telephone Number  
Fax Number  
Contact Person (First & Last Name)  
Contact Person Email Address  
Location Additional Insured Wording (Found in your rental agreement)  
Who is supplying security?*  
Is security armed?*  
Underwriting Information
 
List anyone else you need to name as Additional Insured on your policy  
Describe First Aid/Medical arrangements*  

Will shoot include any Stunts, Pyrotechnics, Aircraft, pools, lakes or other bodies of water, Car Races, Rides or other Hazardous Activities?*

 

 

 
If yes, please explain  
Who was your previous insurance company*  
Premium paid: $*  
List all previous claims (Last 5 years)*  

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.

 

 

 

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.

 
Number of vehicles rented or borrowed?  
Number of vehicles used by employees?  
Total cost to rent vehicles:  
If physical damage to rented vehicles is desired, what is the maximum value of any one vehicle?  
What is the total value of all vehicles?  

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.

 
Description of Equipment  
Describe protection, security at principal location  
Value of Owned Equipment: $  
Value of Rented Equipment: $  
Value of Sets, Props & Wardrobe: $  
Total Values: $  
Include Negative, Faulty Stock & Camera Processing coverage?  
Include Extra Expense?  
Include 3rd Party Property Damage?  

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.

 
Number of Full Time Employees  
Number of Part Time Employees  
Total Payroll (W-2, 1099, Deferred and other payroll)  
Payroll Company (if any)  
Full names and titles of all owners or officers. Coverage will be excluded for these persons.  
Employers' Federal I.D. Number  

Weather Insurance Option

If your production would be affected by bad weather, consider buying Rain / Snow / Wind / Lightning coverage

 
Coverage Date  
Coverage Times From To  
Policy Limit: $  
Include the following perils

Rain:

Lightning:

Snow:

Wind:

 
List any additional dates and times in the Additional Notes section below
 

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.

 
Is the shoot indoors?  
If no, is the filming area under a cover?  
Would bad weather cause cancellation of your shoot?  
List the Actors or other key persons and their ages whose non-appearance would cause a delay in the production  
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