Film/Video Application

Applicant's Name: *

Email Address: *

Address:

City:

State:

Zip Code:

Telephone:

Fax:

Broker:

Contact:

Experience of Applicant (Please attach resume): *

Upload Resume:

Loss Experience: *

Budget:

Term of Coverage (From To): *

Name of Shoot: *

Client: *

Synopsis of Shoot: *

Principal Photo: 2 Weeks Maximum, Location & Dates of Shoot: *

Coverage   Limit   D/A
Negative   $GPC of Production   None
Faulty   $GPC of Production   $5,000
Props, Sets & Wardrobe   $50,000   $500
Miscellaneous Equipment RC   $500,000   $2,500
Extra Expense   $100,000   $1,500
Third Party Property   $250,000   $1,000
CGL   $1,000,000/$2,000,000/$1,000,000   None
NOHA Liability   $1,000,000   Non
The limits and pricing of this program conemplate no stunts or other hazardous activities, no pyrotechnics, no aircraft, no watercraft, no animals an no foreign exposure. (Domestic- U.S. & Canada). Any involvement in the above requires no prior written notification and underwriting consideration by us; appropriate additional premiums will be assessed.

**Please note: Policy Excludes Deferments & All Premiums Must Be Paid Prior To Inception/Binding.**