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631-841-0270
eeaton@eatoninsurance.com
Fax- (631) 841-0509
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Photographer Package
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Insurance Form
Photographer Package
Application Form
Please complete this form and we will contact you with a quote
Applicant 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
If yes, Please provide detail below for each policy:
Describe your typical shoots: *
Are there stunts and/or hazardous activities?
Yes
No
If yes, please describe
Photographer Detail
Years of Experience *
Annual Revenue *
Number of shoots per year *
Number of employees *
Do you hire freelancers
Yes
No
If yes, how many and estimated pay:
Coverage
General Liability
--- Select ---
1,000,000
2,000,000
Excess Liability
--- Select ---
1,000,000
2,000,000
3,000,000
5,000,000
Value of owned camera equipment *
Value of rented camera equipment *
Value of office/studio contents
Workers compensation
Yes
No
If yes, estimated annual payroll
Do you wish to be covered?
Yes
No
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