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 Website First Name Driver's Lic # E-mail State of Issuance 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 Phone Role in the Production Fax Country of Residence Other phone Production Total Gross Production Budget What are the dates of your production? (If insuring rented equipment start with pick-up and end with drop-off day) Start 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... 2001 2002 2003 2004 2005 2006 2007 2008 End 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... 2001 2002 2003 2004 2005 2006 2007 2008 Project Title Type of Production Please select: "The Making Of" Videos Animation Commercial Community TV Interview Corporate Video Demo Reel Shoot Digital Video Direct Sale Videos Director's Reel Documentary Educational & Training Film Experimental Film Feature Film Festival Film Film Promotion Independent Feature, Low Budget Industrial Infomerical Instructional Video Live Action Shot Miscellaneous Production Motion Picture Music Video Non-Airing Pilot Photography Shoot Pick-up Shoot Point of Sale Video Promtional Video Public Access Program Public Service Announcement Reality Based TV Show SAG Experimental SAG Limited Exhibition SAG Modified Low Budget Sales Video Short Film Spec Commercial Spec Production Television Pilot Television Series Television Special Thesis Film Trailer Training Video Video Biography Video Location Survey Video Shoot (Miscellaneous) If Music Video Music Category Please Select a Misic Category: Alternative Blues Children's Music Classical Country Electronic Folk Hard Rock/Heavy Metal Hip Hop/Rap Jazz Latin Experimental Film New Age Opera Pop R&B/Soul(other than hip-hop, rap) Reggae Rock World Music Decade Please Select the Music Decade: Prior to 50's 50's 60's 70's 80's 90's 2000 and beyond Artist Name Film Location(s) Brief description of project General Liability Limit Please Select: NONE $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 Do you require auto liability coverage? yes no Do you also require auto physical damage coverage? Exclude $125,000/$500,000 $250,000/$500,000 Underwriting Questions Please answer the following questions to determine if the production qualifies for short term production insurance 1. Underwriting Questions a. 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 b. Are there any unprotected or open heights above or below 15 feet? (Relates to Worker's compensation) c. Are there any employees supplied to or from an employee leasing operation (i.e. PEO)? (Relates to Worker's Compensation) yes no yes no d. Is coverage required outside of the US and Canada? yes no e. Applicant agrees that only one production can be covered by the policies issued yes no f. Applicant agrees that if Workers Compensation coverage is obtained exclusion of coverage for officers and owners will apply yes no g. Applicant agrees that if Workers Compensation coverage is obtained exclusions of coverage for stunts and hazard activities will apply yes no 2. Claim History Any prior production with any losses of any kind declared by the insured? yes no Worker's Compensation Is worker's compensation required? yes no Federal ID or Social Security Number Number of full-time Employees Number of part-time Employees Number of volunteers Shoot Days Any SAG members? yes no Payroll Breakdown W-2 1099 Deferred Other Payroll Company Desired Property Coverage Please state total replacement value broken into the following categories: Rented Equipment Props, Sets & Wardrobe Would you like our quote to include any of the following: Faulty Stock & Negative Film? yes no 3rd Party Property Damage? Please select: None $250K $500K $1M $1.5M $2M Extra Expense Coverage? yes no Your Owned Equipment? yes no If yes, provide total replacement value: $ Comments What specific type of raw stock will you be using? Would you like our product division to provide a price quote? Please select: Yes No 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.