Short Term Production Application

Movie Boat Application
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 Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *

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

I Understand

UNDERWRITING QUALIFICATION
Will the production include any Stunts, Water-skiing or over-the-side activities? *

Yes No
If yes, please describe. *
Will the production take place outside the US or Canada? *

Yes No
If yes, please explain: *

Insurance History
Have you had any prior insurance coverage? *

Yes No

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

Yes No
If yes, please explain: *
Any losses in the past 3 years? *

Yes No

	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 *
Estimated costs, including overhead, chargeable directly to the production stated at the time of declaration of an insured production or series of productions. The following costs are not included: story, scenario, music rights, sound rights, royalties, residuals, continuity, premiums paid for the insurance, interest on loans and taxes.

Filming Locations: (One Per State) *

	Street Address	City	State	Zip Code	Name of Venue
Location 1
Location 2
Location 3
Location 4

Coverage Start Date *

Month Day Year
Date
Coverage End Date *

Month Day Year
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).
Production Personel
Producer’s or EP’s name: *
Contact phone number: *
Email *
example@example.com

HULL & MARINE LIABILITIES
Pollution *

Include Exclude
Wharfinger's Liability *

Include Exclude
Excess General Liability Limit *
Select only if higher limits are required. Film permit offices, locations typically require the standard $1M liability limit.

INLAND MARINE

Property Coverage such as rented camera equipment etc.
Unscheduled Owned Equipment:
(total replacement cost value)
Rented Equipment, Props, Sets & Wardrobes
(total replacement cost value)
Negative Film/Faulty Stock:

VESSEL DETAILS & COVERAGE

Vessel Details *

	Vessel #1	Vessel #2	Vessel #3
Vessel Name:
Year Built
Manufacturer/Builder
Boat Type
Length (ft)
Registration Number
Market Value ($)

Owner Details *

	Vessel #1	Vessel #2	Vessel #3
Owner Name
Address

Vessel Use

	Vessel #1	Vessel #2	Vessel #3
Days in Operating Use (Not Docked)
Days in Operating Use (Docked)
How will the vessel be used in the production?

Insured Operation

	Vessel #1	Vessel #2	Vessel #3
Is the insured operating the vessel?
Will the vessel be used out of water?

Attachment

	Vessel #1	Vessel #2	Vessel #3
Place of Attachment
Navigation Area to be used:

Will the vessel be used within 50 miles of the attachment?

	Vessel #1	Vessel #2	Vessel #3
Will the vessel be used within 50 miles of the attachment?

Vessel Specific Coverage

	Vessel #1	Vessel #2	Vessel #3
Hull & Machinery

Additional Information, Comments
Additional Information or Comments, if necessary, can be provided.
Would you like to receive a complimentary Errors and Omissions quote for your completed film?

Yes No
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 company pursuant 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.
Do you accept these terms and conditions? *

I Agree
Would you like to recive our quarterly newsletter? *

Yes No
NY License # BR-1001302

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

Movie Boat Application

UNDERWRITING QUALIFICATION

Insurance History

PRODUCTION DETAILS

Production Personel

HULL & MARINE LIABILITIES

INLAND MARINE

VESSEL DETAILS & COVERAGE

Additional Information, Comments