Stunt Questionnaire
Please note: a short term application is also required in order to receive a quote.
Click here for
Insrance Terms & Definitions
.
POLICY HOLDER INFORMATION
Insured Name
*
The name of your production company or entity (or individual name if not incorporated).
Policy Number
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PRODUCTION DETAILS
Project Title
*
Project Synopsis
*
2-3 sentences describing your film's story.
Type of Production
*
Short Film
Commercial
Corporate Video
Documentary
Educational & Training Film
Feature Film
Industrial
Infomercial
Music Video
TV Series / Pilot
Trailer
Student Film
Web Series
Other
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)
*
Rows
Street Address
City
State
Zipcode
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).
Check all that apply to your production:
*
Aerial Scenes
Falls
Fight Scenes
Fireworks
Miscellaneous Pyrotechnic Effects
Demolitions / Explosions
Flashboxes / Flashpods
Recreational Vehicles
Water Scenes
Weapons
Precision Driving
Chase Scenes
Vehicle Collisions
Vehicle Explosions
Animals
Do you have any other stunt activities that are not listed above?
*
Yes
No
If yes, please provide details:
*
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Production Personel
Producer’s or EP’s name:
*
Contact phone number:
*
Email
*
Confirmation Email
example@example.com
Driver's License Number
State
Are you using a stunt coordinator?
*
Yes
No
Stunt Coordinator Name:
Stunt Coordinator's Phone Number:
Stunt Coordinator's Email:
Stunt Coordinator's IMDB Link:
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Aerial Scenes
Shoot from:
*
Commercial Airline
Other Private Aircraft
Private Plane
Propeller Plane
Helicopter (equipment < $500,000)
Helicopter (equipment > $500,000, $1,000,000)
Hang-glider
Parachute
Hot Air Balloon
Drone (Owned by Insured)
Drone (Rented from 3rd Party)
Detailed description of aerial scene(s):
*
Number of scenes with involve aerial photography:
*
Start Date of Aerial Shoot
*
-
Month
-
Day
Year
Date
End Date of Aerial Shoot
*
-
Month
-
Day
Year
Date
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Falls
Detailed Description of scene(s):
*
Number of scenes with involve a fall:
*
Start Date on with fall(s) will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which fall(s) will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Fight Scenes
Physical Contact (Check all that apply)
*
No Physical Contact
Physical Contact (No Weapons)
Physical Contact (Weapons)
Detailed description of scene(s):
*
Number of scenes which involve a fight:
*
Start Date on which fight(s) will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which fight(s) will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Fireworks
Please select one of the following:
*
Minimal Risk Effect (Minimal risk effect will be 100% controlled, at least 500 feet away from the public and property. A permit from the fire department is not required. Actors and crew will not be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect.)
Minimal Risk Effect with COI from Pyrotechnician (A certificate of insurance is obtained from the pyrotechnician naming the production company as additional insured.)
Moderate Risk Effect (Moderate risk effect will be 100% controlled, at least 250 feet away from the public and property. A permit from the fire department is not required. Actors and/or crew may be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.)
Medium Risk Effect (Medium risk effect will be 100% controlled, at least 100 feet away from the public and property. A permit is obtained from the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.)
High Risk Effect (High risk effect is 100% controlled and takes place close to the public and/or property. A permit must be obtained and the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.)
N/A
Detailed description of scene(s):
*
Number of Firework effects:
*
Number of scenes which involve fireworks:
*
Start Date on which fireworks will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which fireworks will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Miscellaneous Pyrotechnic Effects
Please select one of the following:
*
Minimal Risk Effect (Minimal risk effect will be 100% controlled, at least 500 feet away from the public and property. A permit from the fire department is not required. Actors and crew will not be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect.)
Minimal Risk Effect with COI from Pyrotechnician (A certificate of insurance is obtained from the pyrotechnician naming the production company as additional insured.)
Moderate Risk Effect (Moderate risk effect will be 100% controlled, at least 250 feet away from the public and property. A permit from the fire department is not required. Actors and/or crew may be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.)
Medium Risk Effect (Medium risk effect will be 100% controlled, at least 100 feet away from the public and property. A permit is obtained from the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.)
High Risk Effect (High risk effect is 100% controlled and takes place close to the public and/or property. A permit must be obtained and the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.)
N/A
Detailed description of scene(s):
*
Number of pyrotechnic effects:
*
Number of scenes which involve pyrotechnics:
*
Start Date on which pyrotechnics will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which pyrotechnics will be filmed:
*
-
Month
-
Day
Year
Date
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Demolitions / Explosions
Please select one of the following:
*
Minimal Risk Effect (100% controlled effect in a small contained area. Minimal, if any, chance for injury or damage to property. Permitting not required. Fire department presence not required. Safety precautions must be provided. Certificate of insurance not obtained from stunt coordinator. Equipment cannot be in close proximity to the effect.)
Minimal Risk Effect with COI from Pyrotechnician (A certificate of insurance is obtained from the pyrotechnician naming the production company as additional insured).
Moderate Risk Effect (Highly controlled effect in a small contained area. Permit obtained from fire department but fire department presence during effect is not required. Safety precautions must be provided. Certificate of insurance not obtained from stunt coordinator. Equipment cannot be in close proximity to the effect.)
Medium Risk Effect (Medium risk effect. Permit obtained from fire department and fire department will be present during effect. Safety precautions must be provided. Certificate of insurance not obtained from stunt coordinator. Equipment cannot be in close proximity to the effect.)
High Risk Effect (Major effect. Permit obtained from fire department and fire department will be present during effect. Safety precautions must be provided. Certificate of insurance not obtained from stunt coordinator. Equipment cannot be in close proximity to the effect.)
N/A
Detailed description of scene(s):
*
Number of demolition / explosion effects:
*
Number of scenes which involve demolitions / explosions:
*
Start Date on which demolitions / explosions will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which demolitions / explosions will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Flashboxes / Flashpods
Detailed description of scene(s):
*
Number of scenes which involve flashboxes:
*
Number of flashbox effects:
*
Start Date on which flashboxes will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which flashboxes will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Recreational Vehicles
Recreational Vehicle Type:
*
ATV
Go-Cart
Moped
Scooter
Segway
Motorcycle
Motorcycle (skidding, no collisions)
Motorcycle (off road: no skidding, no collisions)
Motorcycle (race track: no skidding, no collisions)
Snowmobile
Detailed description of scene(s):
*
Number of scenes which involve recreational vehicles:
*
Number of recreational vehicles:
*
Start Date on which recreational vehicles will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which recreational vehicles will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Water Scenes
Please check all that apply:
*
Canoes
Close to shore shoot
Inland Lakes
Kayaks
Surfing
Swimming Pools
Detailed description of scene(s):
*
Number of scenes which involve water shooting:
*
Start Date on which water scenes will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which water scenes will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Weapons
Weapon type:
*
Prop Gun (Guns that discharge other than squibs or blanks)
Blanks
Squibs
Knives
Various use of Squibs, Blanks, Knives, & Prop Guns.
Detailed description of scene(s):
*
Number of scenes which involve weapons:
*
Start Date on which weapons will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which weapons will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Precision Driving
The scripted driving of vehicles on public roads, not including chases, speeding, skidding or collisions.
Which of the following precision driving scenes are involved in this production?
Public Road Driving
Race Track Driving
Off-Road Driving
Detailed description of scene(s):
*
Number of scenes which precision driving:
*
Number of cars:
*
Start Date on which driving will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which driving will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Chase Scenes
Chase Scene Type:
*
Vehicle Chase Scene
Motorcycle Chase Scene
Detailed description of scene(s):
*
Number of chase scenes:
*
Number of vehicles:
*
Start Date on which chase scenes will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which chase scenes will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Vehicle Collisions
Detailed description of scene(s):
*
Number of collision scenes:
*
Start Date on which collision scenes will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which collision scenes will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Vehicle Explosions
Please select one of the following:
*
Minimal Risk Effect (Minimal risk effect will be 100% controlled, at least 1000 feet away from the public and property. A permit must be obtained and the fire department will be present. Actors will not be in the vehicle and crew will be at least 100 feet away.)
Moderate Risk Effect (Moderate risk effect will be 100% controlled, at least 250 feet away from the public and property. A permit must be obtained and the fire department will be present. Actors will not be in the vehicle and crew will be at least 50 feet away.)
Medium Risk Effect (Medium risk effect will be 100% controlled, at least 100 feet away from the public and property. A permit must be obtained and the fire department will be present. Actors will not be in the vehicle and crew will be at least 25 feet away.)
N/A
Detailed description of scene(s):
*
Number of explosion effects:
*
Number of scenes which involve explosions:
*
Start Date on which explosions will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which explosions will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Animals
Which type of animal is involved in this production?
*
Iif it’s a dog, please be specific about the breed.Your answer
Detailed description of scene(s):
*
Number of scenes which the animals:
*
Number of animals:
*
Start Date on which animal(s) will be filmed:
*
-
Month
-
Day
Year
Date
End Date on which animal(s) will be filmed:
*
-
Month
-
Day
Year
Date
Total number of days:
*
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Additional Information, Comments
Additional Information or Comments, if necessary, can be provided.
Submit
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