Application Form

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

    Application 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
    Confirm your understanding that only one production will be covered
    YesNo

    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:

    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
    Excessive Liability

    Auto

    Hired and non owned Auto Liability
    YesNo
    Hired and non owned Auto Physical Damage
    YesNo
    Worker Compensation
    YesNo

    Estimated Shoot Payroll

    Number of shoot days *
    Number of people to be covered *

    Production Coverage

    Misc Rented Equipment *
    Props, Sets & Wardrobe *
    Extra Expense
    YesNo
    Negative Film, Faulty Stock Digital Images
    YesNo
    Third Party Property Damage
     
    Captcha 47 + = 51