[contact-form-7 id=”1108″ title=”Short Term Production”]

Application Form

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

Application Information:

Insured Name *

Entity Type *

Entity Type(Required)

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

If yes, Please explain

Confirm your understanding that only one production will be covered

Confirm your understanding that only one production will be covered

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

Production Detail

Production Title *

Production Budget *

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

Excess Liability

Auto

Hired and non owned Auto Liability

Hired and non owned Auto Liability

Hired and non owned Auto Physical Damage

Hired and non owned Auto Physical Damage

Worker Compensation

Worker Compensation

Estimated Shoot Payroll

Number of shoot days *

Number of people to be covered *

Production Coverage

Misc Rented Equipment *

Props, Sets & Wardrobe *

Extra Expense

Extra Expense

Negative Film, Faulty Stock Digital Images

Negative Film, Faulty Stock Digital Images

Third Party Property Damage

captcha