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Named Insured (Production Co. or Individual)
Entity Type ( Indiv, LLC, LLP, Corp. LLC, Non-Profit, Other)
Mailing Address (P.O. Box - okay)
Contact Person
E-mail Address *
Year Business Established?
Volunteers Box) Volunteers
How many productions are planned within the next 12 months?
Previous Insurance Carrier and Policy Number
Lines of Coverage
Production Title
Type of Production (doc, commi, feature film, music video, etc)
Estimated Gross Production Coast/Total Project Budget
Number of Episodes/Length (if applicable)
Policy Effective Date (Date Coverage Begins)
Pre-Production
Principal Photography
Post-Production
Total Number of Shoot Days
Shooting Location(s) - City & State
Brief Synopsis
Type of Music
Decade of Music
Artist Name
First and Last Name
First and Last Name
First and Last Name
Date of Birth
Date of Birth
Date of Birth
Drivers License #/State
Drivers License #/State
Drivers License #/State
Other
Private Passenger
Trucks/Trailers
Number of Rental Days
Estimated Cost of Hire/rental
Rented Equipment (Camera, Lighting, Sound, etc) $
Rented Props, Sets & Wardrobe $
Owned Equipment, Props, Sets, Wardrobe $
Negative Film & Faulty Stock $
Faulty Stock, Camera & Processing $
Third Party Property Damage $
Extra Expense $
Office Equipment & Furniture/Contents $
Electronic Data Processing (Computer HW/SW/Media) $
1. What is the name of the entity requesting the waiver of subrogation?
What is their involvement in the event?
Number of Shoot Days
Payroll Company Name (if any)
# Full-Time
# Full-Time
# Full-Time
# Full-Time
# Part-Time
# Part-Time
# Part-Time
# Part-Time
Volunteers
Volunteers
Volunteers
Volunteers
Total Payroll(W-2, 1099, Deferred, Other (Please identify)
Total Payroll(W-2, 1099, Deferred, Other (Please identify)
Total Payroll(W-2, 1099, Deferred, Other (Please identify)
Total Payroll(W-2, 1099, Deferred, Other (Please identify)
First Name
Last Name
Title/Position
ADDITIONAL COMMENTS
Insurance Agency Name
Agent Contact Person
Agent Contact Person Email
