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631-841-0270
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Short Term Production
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Insurance Form
Short Term Production
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
Confirm your understanding that only one production will be covered
Yes
No
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:
Production Detail
Production Title *
Production Budget *
Production Date(s) *
Location(s) *
Provide a detail synopsis of the shoot *
Producer Information
Producer's Name *
Phone Number
Email
Driver Licence Number, State
Coverage Limits
General Liability
---Select---
1,000,000
2,000,000
Excessive Liability
---Select---
1,000,000
2,000,000
3,000,000
Auto
Hired and non owned Auto Liability
Yes
No
Hired and non owned Auto Physical Damage
Yes
No
Worker Compensation
Yes
No
Estimated Shoot Payroll
Number of shoot days *
Number of people to be covered *
Production Coverage
Misc Rented Equipment *
Props, Sets & Wardrobe *
Extra Expense
Yes
No
Negative Film, Faulty Stock Digital Images
Yes
No
Third Party Property Damage
---Select---
1,000,000
2,000,000
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