• DICE / Annual Productions Application

    Please fill out the following form in order to receive a quote for insurance.

  • APPLICANT INFORMATION

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  • UNDERWRITING QUALIFICATION

    Please answer the following questions to determine if the production qualifies for short term production insurance.

  • Stunts, Falls, Fight Scenes, Pyrotechnics, Fireworks, Airplanes, Helicopters, Drones, Hangliders, Hot Air Balloons, Parachutes, Boats, Water Scenes, Animals, ATVs, Go Carts, Mopeds, Motorcycles, Scooters, Segways, Snowmobiles, Weapons, Blanks, Squibs, UAV (Drones), Animals, Hard-core or Soft-core Porn, Live Gangster Rap, Precision Driving, or Chase Scenes?

  • Insurance History

  •   Policy Type Carrier Policy # Expiration Date Premium Paid
    Policy
  •   Policy Type Date of loss Description of loss Amount of loss
    Claim 1
    Claim 2
    Claim 3

  • PRODUCTION DETAILS

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    Pick a Date
  •   Street Address City State Zipcode
    Location 1
    Location 2
    Location 3
    Location 4

  • UPCOMING PRODUCTIONS

    Please indicate the number of productions you anticipate in each category over the upcoming 12 months:

  • 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 activities, live events or performances. 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 Enhancements

  • INLAND MARINE

    Property Coverage such as rented camera equipment etc.

  • AUTO

    Vehicles rented for the production. Legal liability coverage for bodily injury or property damage claims arising out of the filming of the picture. Coverage may include the use of rented & non-owned vehicles, including physical damage to the vehicles. Hired/Non-owned auto coverage may be required on city or state roadways. Coverage does not apply to aircraft or watercraft, which must be separately insured. Physical damage to "hired vehicles" must be selected of you wish to insure against damages to the vehicle. Auto Liability coverage applies if you cause damage to vehicles other than your own.

  • CAST COVERAGE

    This coverage is different from Workers Compensation. It is additional coverage for certain KEY cast and crew members.

  • WORKER’S COMPENSATION

    Covers medical injury to your hired cast or crew. This may include W2 employees, 1099 freelancers & volunteers. Available in most states.
  •   Name Street Address City State Zipcode
    Entity #1
    Entity #2
    Entity #3
    Entity #4

  • Additional Information, Comments

  • Terms and Conditions


    Please carefully review the Terms and Conditions below:

    • I represent that this application form has been completed after proper inquiry and, based on this inquiry, I represent the application contents are true, accurate, and not misleading.
    • I represent that I understand and agree that if any of the contents of this application are intentionally untrue, inaccurate, or misleading, in any material respect, or if I fail to notify the insurance company of additional information that might render the contents of this application untrue, inaccurate, or misleading, in any material respect, then the insurance company is entitled to rescind any policy issued pursuant to this application.
    • Any person who knowingly and with intent to defraud any insurance company or another 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 and subjects the person to criminal and civil penalties. Please click the link below for individual state notices.
    • I represent that I understand and agree that this application and all materials submitted in connection with this application are incorporated into and form the basis of any policy issued by the insurance companypursuant to this application.
    • I represent that by signing this application I am representing that I am duly authorized to execute insurance contracts on behalf of the entity applying for this coverage and that all representations (whether verbal or written) made in connection with this application are made on behalf of and shall be fully binding upon such entity.
    • A quotation received is not binding on the Insurer in any way.
    • By clicking 'Submit Application' you are not agreeing to purchase coverage. If terms can be offered you will receive a free, no-obligation insurance quotation via email. All quotes require underwriter’s approval and payment prior to binding. Please read all exclusions indicated on the quotation.
    • Please note that once coverage is bound, the policy cannot be cancelled.
    • The insurance quotation will be based solely on the coverages and limits selected on this application.
    • Please ask your Film Emporium, Inc. representative to further explain coverage details, exclusions (including stunts and/or other hazardous activities), limits or other provisions of any insurance policy, or to request a sample policy form.

    By submitting this application you indicate that you have read and accepted the Terms and Conditions above.

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