DICE / Annual Production Application

APPLICANT INFORMATION

Select how you found our website.

General Liability (Required) Inland Marine (Rented Equipment & Property Coverage) Auto Coverage Cast Coverage Worker's Compensation

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.

First Name Middle Name Last Name

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Area Code Phone Number

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?

	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

Date Date Picker Icon

Indicate your annual gross production costs by using a conservative estimate. This estimate may be used as part of the premium calculation. Example; Should I include a $400k budget project that may happen in months from now? If this project is not guaranteed you may not want to include it as you can report it later once it is green-lit. Include projects based on your previous year(s) activities and what is scheduled for this upcoming year.

	Street Address	City	State	Zipcode
Location 1
Location 2
Location 3
Location 4

Film permit offices, locations typically require the $1M liability limit.

Select only if higher limits are required. Film permit offices, locations typically require the standard $1M liability limit.

(total replacement cost value)

Provides coverage for physical damage to any premises in your care, custody or control

Enter a dollar ammount.

(only select if owned by the insured entity. Example; equipment owned by your DP should be included under rented equipment)

Covers the potential additional expense to rent similar equipment after a loss.

Computers and related equipment, media, software. Software extra expense is automatically included up to 25% of the hardware limit.

Attaches to EDP and provides limited coverage for computer viruses.

Provides coverage for contractually obligated [yet unanticipated] talent, services or facilities costs incurred to reshoot the production after a covered loss.

Include: Blanket Limit Include: Single Limit By Coverage Exclude

Exclude $125,000 / $500,000 $250,000 / $500,000 $125,000 / $1,000,000 $250,000 / $1,000,000 $125,000 / $2,000,000 $250,000 / $2,000,000

Exclude 100% of Gross Production Cost 75% of Gross Production Cost 50% of Gross Production Cost 25% of Gross Production Cost

Exclude $5,000 per person / $25,000 Aggregate $10,000 per person / $50,000 Aggregate $25,000 per person / $100,000 Aggregate

Exclude $1M Guild, $50k Non-Guild, $5M Aggregate $1M Guild, $50k Non-Guild, $10M Aggregate $1M Guild, $100k Non-Guild, $5M Aggregate $1M Guild, $100k Non-Guild, $10M Aggregate $1M Guild, $250k Non-Guild, $5M Aggregate $1M Guild, $250k Non-Guild, $10M Aggregate $1M Guild, $500k Non-Guild, $5M Aggregate $1M Guild, $500k Non-Guild, $10M Aggregate

	Name	Street Address	City	State	Zipcode
Entity #1
Entity #2
Entity #3
Entity #4

Include Full and Part Time Hires

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.

DICE / Annual Productions Application

UNDERWRITING QUALIFICATION

Insurance History

PRODUCTION DETAILS

UPCOMING PRODUCTIONS

GENERAL LIABILITY

General Liability Enhancements

INLAND MARINE

AUTO

CAST COVERAGE

WORKER’S COMPENSATION

Additional Information, Comments