[contact-form-7 id=”1106″ title=”Photographer Package”]

Application Form

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

Applicant Information:

Insured Name *

Entity Type *

Entity Type

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? *

Will any production take place outside the US or Canada(Required)

If yes, Please explain

Insurance History

Any Insurance declined or cancelled in the past 3 years(Not applicable in MO)?

Any Insurance declined or cancelled in the past 3 years(Not applicable in MO)(Required)

If yes, Please explain

Any Prior Insurance Coverage?

Any Prior Insurance Coverage(Required)

If yes, Please provide detail below for each policy

Describe your typical shoots: *

Are there stunts and/or hazardous activities?

Are there stunts and/or hazardous activities(Required)

If yes, please describe

Photographer Detail

Years of Experience *

Annual Revenue *

Number of shoots per year *

Number of employees *

Do you hire freelancers

Do you hire freelancers(Required)

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

Workers compensation(Required)

If yes, estimated annual payroll

Do you wish to be covered?

Do you wish to be covered?(Required)

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