NOTICE: THE LIMITS OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE AND CLAIMS EXPENSES. FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE AND CLAIMS EXPENSES SHALL BE APPLIED AGAINST THE RETENTION AMOUNT. IF THE POLICY IS ISSUED, COVERAGE WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. THE POLICY PROVIDES COVERAGE ONLY FOR THE PRODUCTION TITLE YOU PROVIDE HEREIN. 'You", "Your" or "Applicant" refer individually and collectively to the Applicant and the suthorized agent for the person or entity proposed for this insurance. 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. I. General Information Full Name of Applicant Authorized Agent: First Name: Last Name: Contact E-mail: Applicant Type Please Select... Individual Corporation Partnership LLC Applicant Ownership Please Select... Publicly Traded Privately Held Mailing Address Address2 City State of Formation 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 Telephone Number of Employees Applicant is more than 30% owned by a publicly traded company Yes No Aggregate Limit Sought $1 million $3 million $5 million Per claim limit sought $1 million $3 million $5 million Retention $10,000 $25,000 $50,000 $100,000 Do you have a distribution contact? Yes No II. Production Information Title of Production that is to be insured (Named Production) Please provide a synopsis of Named Production Production Company or Rights Holder Name Address1 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 Phone Named Production Budget $ E&O Requirements of your Distributor Check each that apply in whole or in part to the Named Production and provide requested information where applicable Motion Picture Television Program Theatrical Release No Yes Dramatic Yes No Television Release No Yes Musical, Comedy or Variety Special Yes No Cable/Satellite/Wireless Release Yes No Series Number of Episodes: Yes No DVD/Videotape Release Yes No Pilot Yes No Internet Release Yes No News Yes No Game Release Yes No Documentary Yes No Musical Comedy Yes No Docu-drama Yes No Dramatic Yes No Unauthorized Biography Yes No Documentary Yes No Investigative Yes No Unauthorized Biography Yes No Infomercial Yes No Corporate/Government Film Yes No Children/Animation Yes No Children/Animation Yes No Quiz Panel Yes No Historical/Religious Yes No Reality Yes No Comedy Yes No Radio Program: Music Format Yes No Talk Format Yes No Shock Jock Yes No News Format Yes No Hidden Microphone used during program Yes No Prank phone calls made during program Yes No Religious Yes No Educational Yes No Investigative Yes No Station sponsors music events Yes No Station sponsors concerts Yes No Streamed on Internet Yes No Sports Yes No Consumer Advocacy Yes No Initial Release Airt Date III. Clearance, Licenses, Consents and Releases Have all performers who will appear in the Named Production entered into a written performance agreement with the Applicant related to their appearance? yes no Has the Applicant obtained or will obtain a license, consent or release from those persons, animals or characters who appear in the Named Production without a written performance agreement? yes no In the past three (3) years, have You been given notice of any potential infringement of another party's intellectual property (IP) rights, including without lmitation, copyright or trademark infringement? yes no Do You require freelancers, independent contractors, musicians, composers or others who provide you with content: To assign or license You their rights to the content? yes no To warrant that their work does not violate another party's rights? yes no To indemnify You should an IP infringement claim be made against You? yes no Will the requirements outlined above in question 4 be specifically met with regards to the Named Production? yes no III. Representations and Warranties Has any insurance carrier ever cancelled or non-renewed a policy of Yours that provided the same or similar coverage as the insurance sought? (MISSOURI APPLICANTS NEED NOT APPLY) yes no Are You aware of any claims or legal proceedings made or commenced against You or any of Your officers, members, or partners within the last five (5) years for: (1) invasion of privacy or false light; (2)intellectual property infringement; (3)defamation; or (4) a claim arising out of the alleged submission of any ideas, story line, or script? yes no Are You aware of any claim or threatened clain made against You or any of Your officers, members, or partners arising out of or related to the Name Production? yes no Applicant agrees to obtain from third parties from whom it will obtain services or content for the Named Production written warranties and indemnification against claims arising out of the use of such services or content? Agree Disagree Applicant agrees to use its best efforts to determine whether any content to be used in the Named Production is protected by law and. where necessary, to obtain from parties owning rights therein the right to use same in connection with the Named Production. Agree Disagree Applicant agrees that as a condition precedent to coverage for claims brought by a claimant who either performed or appeared in the Named Production or a claimant who provided either content or services for the Named Production, the Applicant must have prior to the broadcast or distribution of the Named Production a signed agreement or signed release from such claimant agreeing to the respective appearance, performance, use of content, or use of services made in the Named Production. Agree Disagree Applicant agrees that as a condition precedent to coverage for a claim brought by a claimant based on the alleged unauthorized use of title, a title search for the Named Production will have been conducted by a title clearance service and a title report submitted to the carrier prior to the occurrence of said claim? Agree Disagree V. ADDITIONAL DOCUMENTS AND INFORMATION INCORPORATED BY REFERENCE ALL WRITTEN STATEMENTS, MATERIALS OR DOCUMENTS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION, REGARDLESS OF WHETHER SUCH DOCUMENTS ARE ATTACHED TO THE POLICY, ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF, INCLUDING WITHOUT LIMITATION ANY SUPPLEMENTAL APPLICATIONS OR QUESTIONNAIRES. VI. LEGAL NOTICE AND SIGNATURES BEFORE YOU SIGN THIS APPLICATION, READ THESE NOTICES CAREFULLY AND DISCUSS WITH YOUR BROKER IF YOU HAVE ANY QUESTIONS. FOR THE PURPOSES OF THIS APPLICATION, THE UNDERSIGNED DULY AUTHORIZED REPRESENTATIVE OF ALL PERSON(S) OR ENTITIES PROPOSED FOR THIS INSURANCE DECLARES THAT, TO THE BEST OF HER/HER KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS IN THIS APPLICATION, AND IN ANY ATTACHMENTS, ARE TRUE AND COMPLETE THE UNDERSIGNED DULY AUTHORIZED REPRESENTATIVE AGREES THAT IF THE STATEMENTS AND INFORMATION SUPPLIED ON THIS APPLICATION OR INCORPORATED BY REFERENCE CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION AND ANY INFORMATION INCORPORATED BY REFERENCE HERETO, SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IS INCORPORATED INTO AND IS PART OF THE POLICY. SHOULD INSURER ISSUE A POLICY, APPLICANT AGREES THAT SUCH POLICY IS ISSUED IN RELIANCE UPON THE TRUTH OF THE STATEMENTS AND REPRESENTATIONS IN THIS APPLICATION OR INCORPORATED BY REFERENCE HEREIN. ANY MISREPRESENTATION, OMISSION, CONCEALMENT OR INCORRECT STATEMENT OF A MATERIAL FACT, IN THIS APPLICATION, INCORPORATED BY REFERENCE OR OTHERWISE, SHALL BE GROUNDS FOR THE RESCISSION OF ANY POLICY ISSUED. NOTICE TO APPLICANTS: 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 ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. STATE FRAUD DISCLOSURES: NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: 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 FINES AND CONFINEMENT IN PRISON. NOTICE TO COLORADO APPLICANTS: 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 POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER 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 AUTHORITIES. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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. NOTICE TO LOUISIANA APPLICANTS: 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 FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: 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. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. NOTICE TO OHIO APPLICANTS: 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. NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36 §3613.1). NOTICE TO PENNSYLVANIA APPLICANTS: 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. NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. I submit this application as a duly authorized representative of the Applicant and hereby acknowledge that reasonable inquiry has been made to obtain the answers herein which are true, correct, and complete to his/her best knowledge and belief. 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. 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