Insured Name *
Entity Type *
Primary Address (No PO Boxes) *
Mailing Address: (if different from primary)
Contact Name *
Federal ID #
OR Social Security #
Will any production take place outside the US or Canada? *
If yes, Please explain
Any Insurance declined or cancelled in the past 3 years(Not applicable in MO)?
Any Prior Insurance Coverage?
If yes, Please provide detail below for each policy
Describe your typical shoots: *
Are there stunts and/or hazardous activities?
If yes, please describe
Years of Experience *
Annual Revenue *
Number of shoots per year *
Number of employees *
Do you hire freelancers
If yes, how many and estimated pay
Value of owned camera equipment *
Value of rented camera equipment *
Value of office/studio contents
If yes, estimated annual payroll
Do you wish to be covered?