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
 
Captcha 1 + 6 =