Insurance Programs > Short Term Production > Short Term Production Application

Short Term Production Insurance Application for Single Project


Dates Coverage is Needed:
Name Insured: Address (NO P.O.BOX):
Insurance Contact: Phone/FAX: Email:
Producer or Director: P/D's Driver's License # and State

DETAILS OF PRODUCTION


Title: Budget (Gross Prod $)   Production Type:
Synopsis:

UNDERWRITING


Any prior losses on a production? Any employees supplied to or from an employee leasing co? Porn?
Any heights above 15' open or unprotected? International shooting excl. Canada?
Does the shoot involve (if yes specify which): GUNS, BLANKS, SQUIBS, ANIMALS, PYROTECHNICS, STUNTS, BOATS, CAR RACING, MOTORCYCLES,
AIRCRAFT including helipcopters, SNOWMOBILES?

COVERAGE


Occurance/Aggregate

  $1,000,000 / $1,000,000

  $1,000,000 / $2,000,000

  $2,000,000 / $2,000,000

  $3,000,000 / $3,000,000

  $4,000,000 / $4,000,000
    $5,000,000 / $5,000,000

City Certificates

  INCLUDE   EXCLUDE

Waiver of Subrogation

  INCLUDE   EXCLUDE


MARINE


Rented Equipment $
Owned Equipment $
Rented PROPS, WARDOBE and/or SETS $
Negative/Faulty   INCLUDE   EXCLUDE
Third Party Property Damage
  $250,000

  $500,000

  $1,000,000

  $1,500,000

  $2,000,000
Extra Expense
  $10,000

  $25,000

  $50,000

  $100,000

NON-OWNED/HIRED AUTO


Liability
  $1,000,000

  $2,000,000

  $3,000,000

  $4,000,000

  $5,000,000
Physical Damage   $125,000 / $500,000

  $250,000 / $500,000

WORKER'S COMP


How many days of shooting? Payroll (deferred,W-2s,1099s)?   Payroll company?
Is SAG requiring you carry work comp? Officers to be excluded (if any):
How many FULL-TIME cast and/or crew? How many PART-TIME cast and/or crew?

Signature-> Date:



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