120 Broadway Amityville, NY 11701
631-841-0270
eeaton@eatoninsurance.com
Fax- (631) 841-0509
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Annual Productions
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Insurance Form
Annual Productions
Application Form
Please complete this form and we will contact you with a quote
Application Information:
Insured Name *
Entity Type *
Individual
S-Corp
C-Corp
LLC
Primary Address: (No PO Boxes)
City: *
State: *
Zip: *
Mailing Address: (if different from primary)
City:
State:
Zip:
Contact Name:
Phone:
Email Address:
Website:
Federal ID # *
OR Social Security # *
Under Writing Qualification:
Will any production take place outside the US or Canada?
Yes
No
If yes, Please explain
Insurance History
Any Insurance Declined or cancelled in the past 3 years(Not applicable in MO)?
Yes
No
If yes, Please explain
Any Prior Insurance Coverage?
Yes
No
Are there stunts for hazardous activities?
Yes
No
Description of your typical stunts
Production Detail
Years of Experience *
Annual Gross Production Costs($) *
Maximum Budget Per Production($) *
Number of Productions per Year *
Number of Employees *
Coverage Limits
Props, Set & Warddrobe *
Misc, Rented Equipment *
Owned Camera Equipment *
Auto
Do you rent cars?
Yes
No
Do you rent motor homes?
Yes
No
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