Short Term ProductionApplication FormPlease complete this form and we will contact you with a quotePersonal Information:Insured NameEntity Type Individual S-Corp C-Corp LLCPrimary Address (No PO Boxes)CityStateZipMailing Address:Contact NamePhoneEmail WebsiteFederal ID #OR Social Security #Under Writing QualificationWill any production take place outside the US or Canada? Yes NoIf yes, Please explainConfirm your understanding that only one production will be covered Yes NoInsurance HistoryAny Insurance declined or cancelled in the past 3 years(Not applicable in MO)? Yes NoIf yes, Please explainAny Prior Insurance Coverage? Yes NoIf yes, Please provide detail below for each policyProduction DetailProduction TitleProduction BudgetLocation(s)Provide a detail synopsis of the shootProducer InformationProducer's NamePhone NumberEmail Driver Licence Number, StateCoverage LimitsGeneral Liability1,000,0002,000,000Excess Liability100000020000003000000AutoHired and non owned Auto Liability Yes NoHired and non owned Auto Physical Damage Yes NoWorker Compensation Yes NoEstimated Shoot PayrollNumber of shoot daysNumber of people to be coveredProduction CoverageMisc Rented EquipmentProps, Sets & WardrobeExtra Expense Yes NoNegative Film, Faulty Stock Digital Images Yes NoThird Party Property Damage1,000,0002,000,000CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
