*Required
 
Company Information
 
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.)

 
First date property will be in your possession*  
Last date property will be in your possession*  
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

 
Owned Editing & Post-Production Equipment
(Film & Video, Computer Generated Special Effects, Audio Sweetening, Animation, etc.
)
 
Owned Recording & Studio Equipment
(In Studio Equipment
)
 
Owned Sound Recording Equipment (On Location, In Transit)  
Owned Musical Instruments & Band Equipment (In Studio & On Location, In Transit)  
Owned Camera & Production Equipment (Still, Video & Motion Picture Cameras, Grip, Lighting, Lenses & Related Equipment. In Studio and On Location)  
Owned Sound & P.A. Equipment (Sound Amplification / Reinforcement)  
Owned Office Contents  
Rented Equipment (Maximum Value of Equipment You Rent or Borrow From Others)  
Owned 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 $5,000, Description, and Replacement Cost Value

 
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