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 NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Website
Description of your operations:*

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

YesNo
If yes, please describe.*
Will the production take place outside the US or Canada?*

YesNo
If yes, please explain:*

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*
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)*

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

HULL & MARINE LIABILITIES
Pollution*

IncludeExclude
Wharfinger's Liability*

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

Vessel Details*

Owner Details*

Vessel Use

Rows	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

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

Attachment

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

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

Vessel Specific Coverage

Rows	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?

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
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Movie Boat Application