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 Primary Contact Last Name First Name E-mail Phone Cell Phone Fax Federal ID or Social Security Number Qualification Questions Any prior production with losses of any kind? yes no Does production include any stunts, pyrotechnics, or underwater activities? yes no Production Details Type of Production Title of Production Budget (Gross Production Cost) Brief Description/ Synopsis of Shoot Maximum Budget per single shoot Countries & Cities of Shooting Locations Coverage Options Start 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 2010 2011 End 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 2010 2011 For Music Videos Only Type of Music Music Decade Artist Name Coverage Options Rented Equipment Props, Sets & Wardrobe limit (maximum $250,000) None $50K $75K $100K $150K $200K $250K Negative Film/Faulty Stock? (limit equals your budget- up to $25K) Include Exclude General Liability $1,000,000 Aggregate / $1,000,000 Occurrence Limit Include Exclude Worker's Compensation Number of employees from US/Canada Maxiumum # of employees per location Maxiumum # of employees per hotel Number of employees per flight (maximum=-5) 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.