* required
1. Name of Production Company (Applicant): *

2. Address: *

    City:*     State:*

    Zip:*

    Email: *

3. Applicant is: Individual, Partnership, Corporation

4. List prior productions of Producer:

a. Previous Insurer:

b. Has the applicant ever had any form of insurance cancelled or declined?
Yes No
If "yes" Explain:

c. Describe any previous losses of $10,000 or more (insured or uninsured) sustained by the Producer:

5. Indicate financing source:

6. Release or distribution organization:

7. Indicate Film Completion Bond Company, If any:

8. Indicate whether the production is:

1. Motion Picture Feature for Initial Theatrical Release
2. Television Production
• Motion Picture Feature Pilot Special Series Mini Series Other
• Indicate running time: (30 min., 60 min., 90 min., etc.):
• If a Series indicate number of episodes:

9. Title of Production:

10. Type of Story (Drama, Comedy, Musical, Western, etc.):

11. Describe all shooting locations (include City & State or Province and number of weeks at each):

12. Describe all special stunts, and scenes involving animals, underwater shooting, motorcycles, special vehicles, aircraft, watercraft, railroad cars or equipment, fire sequences, explosives, or any other possibly hazardous activities:

13. Estimate costs of each productions or episode:

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

Story/Underlying Rights Sound Rights Royalties

Direct Overhead Music Rights

Amount of Overhead directly chargeable to the production:

Are there any Deferments? If so, explain in detail.

Person to contact for audit:

Phone:

14. Negative / Videotape

Name and location of:

a. Laboratory to be used:

b. Vaults to be used:

c. Cutting rooms to be used:

Any special film processes, special effects or equipment (e.g. Panavision, Cinerama, Imax, etc.):

Negative/Videotape to be transported to processing lab/post production facility:

Via: Frequency:

Coverage to be effective:

Estimated completion date of Protection Print:

Limit of Liability: $

Faulty Stock, Camera and Processing

Will the applicant test cameras, lenses, raw stock, and equipment until proved to be sound prior to commencement of filming or taping (explain procedures)?

Limit of Liability: $

Props, Sets, Wardrobe

Value of Owned $ Rented: $

List any antiques, objects of art, furs, jewelry, precious or semiprecious stones/metals/ alloys in excess of $10,000:

Coverage required from: Until

Limit of Liability: $

Miscellaneous Equipment

Value of Owned $ Rented: $

List any item(s) over $50,000:

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

Where will equipment be kept during use?

Location to which equipment will be returned when not in use?

Coverage required from: Until

Limit of Liability: $

Third Party Property Damage:

Brief description of property (other than miscellaneous equipment, props, sets, etc.) or facilities to be used in connection with the production for which the applicant may be responsible

Coverage required from: Until

Limit of Liability: $