E&O for Distributors Application

E&O (For Distributors) Insurance Application

Please fill out the following form in order to receive a quote for insurance.
Click here for Insurance Terms & Definitions.
APPLICANT INFORMATION
How did you hear about us?*
Select how you found our website.
Applicant / First Named Insured (including DBAs):*
NOTE: First Named Insured is responsible for premium payment, cancellation and changes – refer to specimen policy.
Entity Type*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Website
Date of formation:*

MonthDayYear
Date
Name(s) of Company Principals:
Please note: For purposes of this application, “you/your” includes the Applicant and any other persons or entities seeking coverage under this insurance on whose behalf the Applicant is authorized to submit the following information.

Your Coverage Requests:
Desired Policy Limit(s)

Each Loss: Aggregate:

Desired policy limit(s):
Desired Retention:

$10,000$25,000Other
Please indicate the type of coverage requested:

Acquisition and development only:Distribution only:Film library only:A and D/distribution:A and D/film library:A and D/distribution/film library:

	Each Loss:	Aggregate:
Desired policy limit(s):

Your Financial Information:
For A and D activities, estimate expenditures for all acquisition and development activities for the upcoming year:
For distribution or film library activities, estimate gross revenues from all distribution activities for the upcoming year:
Your A and D Details:

Please estimate the number and types of productions to be acquired or developed:

	Number of Productions
Films for theatrical release:
Films for television:
Films for DVD:
Television series:
Reality television:
Webisodes/internet productions:
Docu-dramas:
Documentaries:
Animation:
Game/quiz shows:
Other (please specify):

What is the average production budget of productions acquired or developed?
Do you accept unsolicited submissions outside of agents or lawyers submissions?

YesNo
If Yes, what are your unsolicited submissions procedures? *
What percentage of projects (either acquired or developed) do you also produce post principal photography?
Please provide a list and description of projects currently in development:

Has any insurer declined, cancelled, or refused to renew any similar insurance issued to you ? (If you are a Missouri applicant/agent, do not answer this question):

YesNo

Claims Representation:
Have you suffered any loss or has any claim, whether successful or not, ever been made against you that would be covered by this insurance?

YesNo
If Yes, please provide full details including the date of each claim or loss, the amount of the claim, defense costs paid, and any remedial action taken:
Are you aware of any problem likely to lead to you suffering a loss or a claim being made against you that would be covered by this insurance?

YesNo
If Yes, please specify details of each problem:

Additional Information, Comments
Additional Information or Comments, if necessary, can be provided.
Would you like to receive our quarterly newsletter?*

YesNo
NY License # BR-1001302

CA License # 0I36156 - dba in CA as New York Film Emporium Insurance Services
Should be Empty:

	Name:	Firm Name	Firm address:	Years of Media/Intellectual Property Law experience:	Telephone:	Email:
Attorney
Attorney
Attorney
Attorney

E&O (For Distributors) Insurance Application