Short Term Production Application

Short Term Production Application

For Feature Films, Documentaries, Short Films, Music Videos, Commercials, Etc.
Click here for Insurance Terms & Definitions.
APPLICANT INFORMATION
How did you hear about us?*
Select how you found our website.
Insured Name*
The name of your production company or entity (or individual name if not incorporated) you would like to insure. Use the same name as on your rental quote.
Entity Type*
Full Name*

First NameMiddle NameLast Name
Address (USA Only)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Format: (000) 000-0000.
E-mail*

Confirmation Email
Website
Description of your operations:*
Federal Tax ID or Social Security Number May Be Required if obtaining Workers Compensation*

I Understand

Any insurance declined or canceled in the past 3 years (not applicable in MO)?*

YesNo
If yes, please explain:*
Any losses in the past 3 years?*

YesNo

Rows	Policy Type	Carrier	Policy #	Expiration Date	Premium Paid
Policy

Rows	Policy Type	Date of loss	Description of loss	Amount of loss
Claim

PRODUCTION DETAILS
Project Title*
Project Synopsis*
2-3 sentences describing your film's story.
Type of Production*
Artist Name*
Genre of Music*
Brief description of the music video:*
How many episodes?*
Length of each Episode?*
Total Gross Production Budget*
Total production expenses incurred during the dates requested below.

Filming Locations: (One Per State)*

Coverage Start Date*

MonthDayYear
Date
Coverage End Date*

MonthDayYear
Insurance exp. is 12:01am. If your last day or filming is April 25th use April 26th as the last day of coverage (as it will expire on 04.26 12:01am).
Are you Renting Equipment?*

YesNo
Equipment Pickup Date*

MonthDayYear
Date
Equipment Drop Off Date*

MonthDayYear
Date
Production Personel
Producer’s or EP’s name:*
Contact phone number:*
Email*
example@example.com

GENERAL LIABILITY

General Liability covers payments the insured will become legally obligated to pay as a result of Bodily Injury or Property Damage arising out of an occurrence during filming your scheduled activities. Applies to third parties, excluding your own cast and crew, location. Injury to your own cast and crew can be covered under workers compensation, if selected. If you would like a quote with workers compensation a separate application is be required.
General Liability Limit*
Occurrence/Aggregate. Film permit offices, locations typically require the $1M liability limit.
Excess General Liability Limit
Select only if higher limits are required. Film permit offices, locations typically require the standard $1M liability limit.
General Liability Enhancements
Waiver of Subrogation

IncludeExclude

WORKER’S COMPENSATION

Covers medical injury to your hired cast or crew. This may include W2 employees, 1099 freelancers & volunteers. Available in most states.
Do you require Worker's Compensation Coverage?*

YesNo
Worker’s Comp limit of $1,000,000*

IncludeExclude
Waiver of Subrogation

IncludeExclude

Rows	Part Time	Full Time
Number of Employees

Additional Information, Comments
Are you planning on getting a Film LA permit?*

YesNoNot sure
Additional Information or Comments, if necessary, can be provided.
Would you like to receive information on Errors and Omissions (E&O) coverage? E&O insurance will be required prior to release.*

YesNo
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:

UNDERWRITING QUALIFICATION