Contact Information
  • Name of Insured                        
  • Entity Type   Individual  Partnership   Joint Venture   LLC Corporation
  • Street Address                            
  • City                                            
  • State Zip   
  • Contact Person                          

  • Phone   Fax

  • Email                                           
  • Federal ID or Social Security #

Qualification Questions
Any stunts, pyrotechnics, aircraft, boats, animals, race tracks, race courses,
helicopters, motorbikes, snowmobiles, blanks, squibs, guns, live rap music?

 Yes No
Any insurance cancelled or declined in past 3 years? (not applicable in Missouri) Yes No
If Yes, please explain
Any losses in past 3 years? Yes No

If Yes, total amount of losses $

Production Details
Number of Production for upcoming 12 months by category
Animation Music Video
Commercial / Promotion / Sales Video Photography Shoot
Documentary / Interviews / Biography Pick-up Shoot
Editing / Trailer Pre / Post Production
Educational /Instructional / Training PSA / Public Access Program
Feature Film Reality Based TV Show
Independent Feature SAG Production
Industrial/Corporate Video Short Film
Infomercial Spec Production
Miscellaneous Productions TV Pilot / Series / Specials

Total aggregate budget for all shoots
Average duration in days per production
Maximum budget per single shoot
Cities and States of shooting locations
Coverage Options

Effective Date of Coverage

Property Limit to Insure
  • Rented Equipment Limit
  • Owned Equipment Limit
  • Props, Sets, Wardrobe Limit
  • Negative Film / Faulty Stock
  • Third Party Property Damage
  • Extra Expense
  • Office Contents

General Liability
Occurrence / Aggregate Limit $1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $2,000,000
$3,000,000 / $3,000,000
$4,000,000 / $4,000,000
$5,000,000 / $5,000,000
Blanket Additional Insured / Certificates of Insurance

 Include Exclude
City Certificates Requiring Special Wording

 Include Exclude
Waiver of Subrogation

 Include Exclude

Hired & Non-Owned Auto
Liability $1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Physical Damage $125,000 per vehicle, $500,000 aggregrate

 Include Exclude
Worker's Compensation
Number of Cast Crew Volunteers
Payroll W-2 1099 Deferred Other
Payroll Company Name (if any)
Officer 1 Name and Title
Officer 2 Name and Title

Authorized Agent Date

         

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