IMPORTANT: Please provide a US address. No PO Boxes.
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| Name of Production Company |
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| Address |
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| Address2 |
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| City |
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| State |
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| Zip |
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| Phone Number |
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| Mobile Phone Number |
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| Country |
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| Entity Type |
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| If Applicant is a Corporation, |
Please provide the following names |
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President
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Vice President
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Secretary
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Treasurer
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Director
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Producer
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Production Manager
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Director of Photo
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| Producer's Prior Productions |
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Title
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Insurance Carrier
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Title
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Insurance Carrier
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| Has the producer had any Production Insurance declined or canceled in the last 5 years? |
yes
no
If yes, please explain |
| Losses over $50,000 in the last 5 years: |
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| Source of Financing: |
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| Release or Distribution organization: |
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| Completion Bond Company (if none, please say so): |
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Premium Audit Contact:
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Phone Number:
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| Production Title |
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| The Production is: |
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| If a Television Production Please select: |
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Running Time: (e.g. 30 min, 60 min, 90 min)
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If "other" please describe
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Number of Episodes
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| Type of Story (e.g. Drama, Comedy, Musical, Western) |
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| Storyline: |
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| Shooting Locations used during Principal Photography: |
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| Description of Location :(including City, State and Country) |
Period of Time at Each Location: |
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| Medical Facility: |
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| Describe arrangements made for First Aid and access to medical facilities and indentify the person in charge and responsible for making arrangements |
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| The production invloves: (check all that apply) |
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Use of Animals
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Underwater Filming
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Motorcycles
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Special Vehicles
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Airborne Crafts
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Waterborne Crafts
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Railroad Cars or Equipment
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| If any of the above are mentioned, please describe in detail: |
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Pyrotechnics (Explosions, Fire)
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If "yes": Please download and complete the following Stunt Questionnaire and fax to 212-683-2740 or 888-229-6247 |
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Stunts or Hazardous Activities
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If "yes": Please download and complete the following Stunt Questionnaire and fax to 212-683-2740 or 888-229-6247 |
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Estimated Cost of Each Production for Episode:
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| a. Total Budget |
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| b. Story/Scenario: Screenplay & Re-wiriting & Associated Costs |
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| c. Music, Sound Rights, Records and Royalties |
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d. Gross Insurable Production Costs
(a minus b & c) |
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| e. Post Production Costs |
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| f. Net Insurable Productions Costs (d minus e) |
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| g. Total Below the Line Costs |
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| Indicate if any of the following OPTIONAL ITEMS are to be insured: |
| Story/Underlying Rights, Screenplay, Re-writes |
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| Sound/Music Rights, Recording Costs |
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| Indirect Overhead |
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| Royalties |
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Other (describe)
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Converage Desired
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| Extended Pre-Production Cast Protection |
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Described Artist 1
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Artist 1 Role
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Artist 1 Age
Artist 1 Limit of Coverage
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Artist 1 Coverage Period
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Described Artist 2
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Artist 2 Role
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Artist 2 Age
Artist 2 Limit of Coverage
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Artist 2 Coverage Period
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Described Artist 3
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Artist 3 Role
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Artist 3 Age
Artist 3 Limit of Coverage
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Artist 3 Coverage Period
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Described Artist 4
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Artist 4 Role
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Artist 4 Age
Artist 4 Limit of Coverage
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Artist 4 Coverage Period
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| Total Limit Pre-Production Cast Protection: |
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| Are employment contracts "Pay or Play"? |
Do employment contract contain "Tie-in Arrangements"?
If yes, explain |
| Will any persons insured by the policy be involved in any hazardous activities during the term of the coverage? |
If yes, explain |
Note: Please fax a copy of Contract or Deal Memo for each person insured to 212-683-2740 or 888-229-6247
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| Principal Photography Cast Protection |
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| Please give particulars on any Stop Date answered "Yes": |
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| Period of Pre-Production: |
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| Period of Principal Photography: |
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| Limit of Coverage: $ |
Deductible: $ |
| Coverage |
Effective |
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| Post Production Cast Protection |
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Please give particulars on any Stop Date answered "Yes": |
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