Application Form

    Please complete this form and we will contact you with a quote

    Applicant Information:

    Insured Name *
    Entity Type *
    IndividualS-CorpC-CorpLLC
    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? *
    YesNo
    If yes, Please explain

    Insurance History

    Any Insurance declined or cancelled in the past 3 years(Not applicable in MO)?
    YesNo
    If yes, Please explain
    Any Prior Insurance Coverage?
    YesNo
    If yes, Please provide detail below for each policy:
    Describe your typical shoots: *
    Are there stunts and/or hazardous activities?
    YesNo
    If yes, please describe

    Photographer Detail

    Years of Experience *
    Annual Revenue *
    Number of shoots per year *
    Number of employees *
    Do you hire freelancers
    YesNo
    If yes, how many and estimated pay:

    Coverage

    General Liability
    Excess Liability
    Value of owned camera equipment *
    Value of rented camera equipment *
    Value of office/studio contents
    Workers compensation
    YesNo
    If yes, estimated annual payroll
    Do you wish to be covered?
    YesNo
     
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