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Name Insured
Country of Residency (If Individual)
Country of Residency (All others)
Contact Person
E-mail Address
Year Business Established
Policy Type / Line of Business
Date of Loss
Description
Amount of Loss
Policy Type
Carrier
Policy #
Expiration Date
Premium
If yes, provide details
Working Title
Type of Production: Please select "The Making Of" Videos Animation Commercial Community TV Interview Corporate Video Demo Reel Shoot Digital Video Direct Sale Videos Director's reel Documentary Educational &Training Film Experimental Film Feature Film Festive FIlm Film Promotion Independent Feature, Low Budget Industrial Infomerical Instructional Video Live action Shot Miscellaneious Production Motion Picture Music Video Non-Airing Pilot Photography Shoot Pick-up Shoot Point of Sale video Promotinal Video Public Access Program Public Service Announcement Reality Based TV Show SAG Experimental SAG Modified Low Budget Sales Video Short Film Spec Commercial Spec Production Television Pilot Television Series Television Special Thesis Film Trailer Training Video Video Biography Video Location Survey Video Shoot (miscellaneous)
Gross Production Cost
Number of Episodes (If applicable)
Production Start Date
Production End Date
Shooting Locations(s) - Cities & States
Synopsis
Type of Music
Music Decade
Artist Name
First & Last Name
Drivers License #
State of Issue
Country of Residence
Detailed Description of Stunt
Date(s) of Stunt
Stunt Coordinators/Professionals, if any
Licensed?
Are permits required?
Have they been obtained?
Describe precautions taken for the safety of the public, participants and property
Any cast members involved/in close proximity
# of vehicles
Maximum speed
Any collisions, explosions
Type of Animal and breed if applicable
Value of Animal
Where will animal be housed during/after filming
Who is responsible during transport
Days of filming
Number of scenes
Any replacements for the animal and can they substitute at all times:
Detailed synopsis of stunt
Occurrence/ Aggregate Limit: Please Select $1,000,000 occ/ $1,000,000 agg $1,000,000 occ/ $2,000,000 agg $2,000,000 occ/ $2,000,000 agg $3,000,000 occ/ $3,000,000 agg $4,000,000 occ/ $4,000,000 agg $5,000,000 occ/ $5,000,000 agg
Blanket Additional Insured/Certificate of Insurance
Rented Props, Sets, Wardrobe
Owned Equipment, Propet Sets, Wardrobe
Negative Film, Videotape $ Digitalized Image
Third Party Property Damage
Extra Expense
Office Contents
Hired & Non-Owned Auto Liability: Please Select Exclude $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000
Hired & Non-Owned Auto Pyhsical Damage (per vehicle/aggregate limit)
If included, provide cert holder name/address
Number of Shoot Days
Payroll Company Name (if any)
# Full Time
# Part Time
Payroll (W-2, 1099, Deferred, Other)
Date of Birth
SSN Title
ADDITIONAL COMMENTS
Insurance Agency Name
Agent Contact Person
Agent Contact Person Email