Media Professional Liability Insurance

Media Professional Liability Insurance

APPLICATION FORM
Please provide all information which may be material to the coverage you wish to purchase and which may influence the decision to insure you, what coverage is offered or the premium charged.
TEST MODE (Unrequires most fields. You must enter revenue.)

On

1 | Your Information

PLEASE ANSWER ALL QUESTIONS.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
National Press Club membership category/ occupation:*

Journalist - FreelanceJournalist - StaffJournalist - AuthorCommunicator - Public RelationsCommunicator - DiplomatCommunicator - News SourceOther
Please describe your occupation.
Your website:
Gross revenue for the last financial year (USD):*
Rev. Helper

2 | Statements of Fact

PLEASE VERIFY ALL STATEMENTS.
I obtain the appropriate licenses for any third party content used at all times.

TrueFalse
I obtain written permission for the use of any individual third party references at all times.

TrueFalse
I am not and will not be involved any investigative, exposé, adult content or true crime work.

TrueFalse (Coverage may be available with additional premium.)
Since you have answered "false" above, please explain.

0/1000
Coverage for investigative, exposé, adult content and/or true crime work is excluded under the standard policy form. It may be included for an additional premium.

I would like to recieve a quote for additional coverage for these exposures.

Policy Limit	Premium	Broker Fees	Total*
$250,000	$400	$75	$475
$500,000	$500	$75	$575
$1,000,000	$850	$85	$935
$2,000,000	$1,250	$125	$1,375

Policy Limit	Premium	Broker Fees	Total*
$250,000	$500	$75	$575
$500,000	$850	$85	$935
$1,000,000	$1,000	$100	$1,100
$2,000,000	$1,500	$150	$1,650

4 | Claims Experience

PLEASE ANSWER ALL QUESTIONS.
Are you aware of any circumstance which may result in a claim under any of the insurance for which you are applying to purchase in this application form?

YesNo
Are you aware of any circumstance which resulted in legal action being made against you within the last 5 years.?

YesNo
Are you aware of any which resulted in cease and desist orders being made against you within the last 3 years.?

YesNo
Please describe the incident including the monetary amount of the potential claim or the monetary amount of any claim paid or reserved for payment by you or by an insurer. Please include all relevant dates, including a description of the status of any current claim which has been made but has not been settled or otherwise resolved and overview of any penalties incurred:

5 | Authorization & Signature

PLEASE REVIEW & SIGN.
Important notice

By signing this form you agree that the information provided is both accurate and complete and that you have made all reasonable attempts to ensure this is the case by asking the appropriate people within your business. CFC Underwriting will use this information solely for the purposes of providing insurance services and may share your data with third parties in order to do this. We may also use anonymized elements of your data for the analysis of industry trends and to provide benchmarking data.

For full details on our privacy policy please visit www.cfc.com
Signature (type your name)*
Should be Empty:

1 | Your Information