Film Emporium Production Insurance Application How did you hear about us? Please select: Google Yahoo Lycos AOL Altavista MSN Other search engine Link from other website Friend/Colleague Newspaper/magazine advertisement A.R.T. NY Flyer Already a Customer IMPORTANT: Please provide a US address. No PO Boxes. Insured Name Address Address2 City State Please select: Canada Other Country AP/AE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Zip Country Entity Type Please Select... Corporation Individual Joint Venture Partnership Other Limited Liability Partnership Trust Non-Profit Limited Liability Corporation Years Experience Primary Contact Last Name First Name E-mail Phone Fax Federal ID or Social Security Number Qualification Questions Any insurance declined or canceled in the past three years? yes no Any Losses in the past three years? yes no If yes, total amount of losses Any Prior Insurance Coverage? yes no Any Stunts, Pyrotechnics, Aircraft, Boats, Animals, Race Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns, Live Gangster Rap Music, Hard-Core/Soft-Core Porn? yes no If yes, plese explain Are there any unprotected or open heights above or below 15 feet? (Relates to Worker's compensation) Are there any employees supplied to or from an employee leasing operation (i.e. PEO)? (Relates to Worker's Compensation) yes no yes no Do you enter into any co-production agreements? yes no Production Details Description of Operations Number of Productions for upcoming 12 months by category Animation Music Video Commercial/Promotional/Sales/Video Photography Shoot Documentary/Interviews/Biography Pick-up Shoot Editing/Trailer Pre/Post Production Educational/Instructional/Training PSA/Public Access Program Feature Film Reality Based TV Show Independent Feature SAG Production Industrial Corporate Video Short Film Infomercial Spec Production Miscellaneous Productions TV Pilot/Series/Specials Total Aggregate Budget for all shoots Average Duration in days per production Maximum Budget per single shoot Cities & States of Shooting Locations Coverage Options Effective Date of Coverage Month... Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year... 2007 2008 2009 2010 2011 Property Coverage Please state total replacement value broken into the following categories: Rented Equipment Props, Sets & Wardrobe Faulty Stock & Negative Film? 3rd Party Property Damage? Extra Expense Coverage? Office Contents Owned Equipment Rental Operations Exclude $25K $50K General Liability Occurence/Aggregate Limit $1,000,000/$1,000,000 $1,000,000/$2,000,000 $2,000,000/$2,000,000 $3,000,000/$3,000,000 $4,000,000/$4,000,000 $5,000,000/$5,000,000 Blanket Additional Insureds/Certificates of Insurance Include Exclude City Certificates requiring Special Wording Include Exclude Waiver of Subrogation Include Exclude Hired & Non-Owned Auto Liability Exclude $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Physical Damage $125,000 per vehicle, $500,000 aggregate Exclude Include Cost of Hire Number of loaned/donated vehicles Number of days Worker's Compensation Number of full-time Employees Number of part-time Employees Number of volunteers Shoot Days Any SAG members? yes no Payroll Need help filling out our insurance forms? Click here to see definitions for our insurance forms. Click here to download a sample document that shows how insurance terms are used in an application — this is a "PDF" document and requires Acrobat Reader, which you can download free from Adobe if you don't have it. Paying by credit card? Click here for a credit card authorization form. Please print, and mail a signed copy to us. All insurance sales are non-cancellable and subject to a 3.5% surcharge.