General Information 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 Flyer Already a Customer IMPORTANT: Please provide a US address. No PO Boxes. Company Name Contact Name First Name Last 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 Phone Alternate Phone Email Website Entity Type Please Select... Corporation Individual Joint Venture Partnership Limited Liability Partnership Trust Non-Profit Limited Liability Corporation Other Qualification Questions Any Equipment losses in the last five years? yes no Principally involved in pornography production? yes no Any coverage canceled or denied in the last 5 years? yes no Do you currently have an equipment floater policy through Fireman's Fund McGee Marine Underwriters? yes no Are you primarily in the business of renting equipment to others? yes no Additional Information Years of Industry experience Description of business operations Address of primary location (if different from address listed above) If scheduled equipment is over $100,000 advise name of central alarm company at primary location Prior Coverage Carrier Name Policy Number Expiration date 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 2011 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 Category Scheduled Equipment Limit to Insure Editing Post/Production Equipment Recording/Studio Equipment Sound/Location Recording Equipment Musical Instruments/Band Equipment Camera/Production Equipment PA/Sound Reinforcement Equipment Office Contents Theatrical Equipment Unscheduled Equipment Rented Equipment Unscheduled Equipment ($10,000 max) Rental Reimbursement (Daily Limit) None $500 $1,000 $1,500 $2,000 $2,500 Extra Expense None $10K $25K $50K $75K $100K Negative Film/Faulty Stock None $10K $25K $50K $75K $100K ARKANSAS, FLORIDA, KENTUCKY, MICHIGAN, MINNESOTA, NEW JERSEY, AND NEW YORK FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and subjects the person to (NY: substantial) criminal and civil penalties. COLORADO FRAUD WARNING: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. MAINE FRAUD WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. NEW MEXICO FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. OHIO FRAUD WARNING: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. PENNSYLVANIA FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 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.