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
 
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