Name of Production Company: 

Entity Type:  Individual   Partnership   Joint Venture   LLC   Corporation

Contact Name:

Contact Title:

Work Phone:      Fax Number:

Federal ID or Soc Sec #:

Email Address:

Name of Production:

Any insurance declined or canceled in past 3 years?  Yes No

Any losses in past 3 years?  Yes No

Type of Production:

Feature Commercial/Promo Music Video Documentary Industrial/Corporate Video

Short Film Photo Shoot TV Pilot/Series/Special Miscellaneous Productions Trailer

Pick-Up Shoot Post-Production Other

# of productions per year, if annual coverage of multiple productions required:

Experience of Applicant:

Number of Years Experience: 

Brief Synopsis Of Film; Genre/Storyline:

Date(s) Of Production:         
From:     To:

Number of Shoot Days:

What Is The Budget Or Topsheet? ($):

Estimated Total Payroll? (for crew only): $

Primary Filming Location
    Address:  
    City:   State:   Zip:  

Additional Filming Locations:
    Address:  
    City:   State:   Zip:  

Any stunts, pyrotechnics, aircraft, boats, animals, race tracks, race courses, helicopters,
motorcycles, snowmobiles, blanks, squibs, guns, live gangster-rap music, soft-core or
hard-core porn: Yes No

Property

Rented Equipment Limit: $

Owned Equipment Limit: $

Props, Sets, Wardrobe Limit: $

Negative Film/Faulty Stock: Include Exclude

Third Party Property Damage: None $250,000 $500,000 $1,000,000

Extra Expense: Include Exclude

Office Contents: $

 
General Liability

Blanket Additional Insureds/Certificates of insurance: Include Exclude

City Certificates requiring Special Wording: Include Exclude

Waiver of Subrogation: Include Exclude

 
Hired & Non-Owned Auto

Physical Damage $125,000 per vehicle, $500,000 aggregate: Include Exclude

 
Other Coverages Available

Additional Comments: