Film Shoot Application

Location Information
Name of Location *
Location Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Will the event take place at more than one location?
If more than one location please include schedule
What limits of liability does the venue require? (Found on your rental agreement) *
Who is supplying the security? *
Is security armed? *
Type of Security (Uniform, Peer Group, Ushers, Etc.)
How many of each?

Underwriting Information
List anyone else (other than location) that need to be listed as additional insured on your policy, include name and complete mailing address.
Will shoot include any Stunts, Pyrotechnics, Aircraft, Pools, Lakes or other bodies of water, Car Races, Rides, Moon Bouncers, Inflatable Activities or other Hazardous Activities? *
If Yes Explain:
Who was your previous insurance company?
Any previous claims (last 5 years)? *
Explain any previous claims
Whould you like an annual quote insuring all of the productions you have planned for the next 12 months?

Hired and Non-Owned Automobile
No. of vehicles rented or borrowed?
No. of vehicles used by employees?
Total cost to rent vehicles?
Any vehicle seat more than 10 passengers?
If physical damage to rented vehicles is desired, what is the maximun value of any one vehicle?
What is the total value of all vehicles?

Property, Negative & Faulty, 3rd Party Property
Description of equipment
Describe protection, security at principal location
Value of owned equipment
Value of rented equipment
Value of Sets, Props & Wardrobe
Total values
Select Additional Coverage

Include Negative, Faulty Stock & Camera Processing Coverage Include Extra Expense Include 3rd Party Property Damage
Any prior claims?
Describe prior claims

Workers Compensation
Name of payroll company (is any)
Employers' Federal ID Number
Number of Full Time Employees
Number of Part Time Employees
List full names and titles of all owners and officers. Coverage will be excluded for these persons

Weather Insurance
Coverage date

Month Day Year
Coverage time

: Hour Minutes AM/PM Option
until
until : Hour Minutes AM/PM Option
Policy limit
Include the following perils (check all that apply)

Rain Lighting Snow Wind
List any additional dates and times for coverage

Production Cancellation
Is the shoot indoors?
Is the filming area under a cover?
Would bad weather cause cancellation of your shoot?
List the actors or other key persons and their ages whose non-appearance whould cause a delay in the production
Application Warranty and Signature
I HEREBY WARRANT AND CONFIRM THAT THE ABOVE INFORMATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, AND FURTHER CERTIFY THAT I HAVE READ ALL OF THE QUESTIONS AND ANSWERS OF THIS APPLICATION. I UNDERSTAND THIS APPLICATION IS A REQUIREMENT FOR COVERAGE, A PART OF THE CONTRACT AND EVIDENCE OF MY ACCEPTANCE OF THIS INSURANCE, AND ANY FALSIFICATION OR MISREPRESENTATION WILL BE DEEMED A BREACH OF CONTRACT, VOIDING ALL INSURANCE COVERAGE. IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED INSURED OR THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING. *

I Accept
Name of person acknowledging Warranty *
Title *
Date of acknowledgment *

Month Day Year
Should be Empty: