1. Name of Production Company
    (Applicant): *

2. Address:*

    *City:     *State:

     *Zip:

   * Email:

3. Applicant is: Individual, Partnership, Corporation, the officers of which are:

President:
Vice President:
Secretary:
Treasurer:

4. Experience of Applicant (examples):

5. Indicate Financing Source or organization used:

6. Release or Distribution organizations or Agencies used:

7. Loss, if any, to be payable to:

8. Productions are on Film Tape, or Both % Film, % Tape.

9. Production personnel are: Union Members Non-Union Members

10. Names and addresses of:

1. Studios to be used:
   
2. Laboratories to be used:
   
3. Vaults to be used:
   
4. Cutting rooms to be used:
   

11. Estimated number of productions to be produced annually:

12. Estimated gross annual production costs:

   Tape $ Film $ Total $

14. Indicate if any of the following optional items are to be insured:

(a) Story (b)Scenario

(c) Music Rights (d) Sound Rights

(e) Royalties (f) Continuity

15. Percentage of Direct Cost to be included as Overhead (if any):

16. Percentage of productions to be filmed outside the U.S. or Canada:

17. Maximum cost any one production: $

18. Maximum length of time any one production from start of photography to date of protection print:

19. Average estimated length of time from start of photography to date of protection print of all productions to be insured:

20. Maximum loss exposure in dollars of any one occurrence: $
(total amount of negative film without protection prints at any one time stored at one location)

21. Description and values at risk: (indicate whether owned or rented and give dollar amount breakdown:)

	Owned	Rented (Highest any one time)	Totals
Props	$	$	$
Sets & Scenery	$	$	$
Wardrobe and Costumes	$	$	$
Cameras & Lenses	$	$	$
Sound & Recording	$	$	$
Electrical & Lighting	$	$	$
Editing & Projection	$	$	$
Other Equipment	$	$	$
Office Contents	$	$	$

If any individual items valued in excess of $25,000.00, give details:

22. Negative to be transported to processing lab:

1. Via:
2. Frequency:

23. Indicate Inventory Control Methods and who is responsible:

24. Any mobile location studio vehicles used? Values:
Describe each unit in detail:

25. Brief description of protection of property (fire fighting equipment, watchman, etc):

26. Has any form of insurance ever been cancelled or declined?
yes no . If "yes", explain:

27. Previous Insurer and Policy No.:

28. Previous Loss Experience:

29. Coverages Desired:

30. Desired effective date of policy: