* required

Applicant:*
Address:*
City: * State:*
Zip:*
Email:*
Phone:
Fax:

Experience of Applicant:

Prior Claims:

Budget: $

Period of Coverage (up to 2 mos.): to

Name of Shoot:

Synopsis of Shoot:

Principal Photography: 2 Weeks Maximum
Location & Dates of Shoot:

Coverage Limit Deductible
Negative $GPC of Production None
Faulty $GPC of Production $5,000
Props, Sets & Wardrobe $50,000 $500
Miscellaneous Equipment RC $5000,000 $2,500
Extra Expense $100,000 $1,500
Third Party Property $250,000 $1,000

Standard Limits and deductibles are shown above. If you should require limits different than those shown, please specify.

Will you also require General Liability coverage? yes no

Will you also require Automobile Liability coverage for Non-Owned or Hired Autos?
yes no

The limits and pricing of this program contemplate no stunts or other hazardous activities, no pyrotechnics, no aircraft, no watercraft, no animals and no foreign exposure. Please complete the stunt questionnaire if this production will involve any of the aforementioned.

Stunts Stunt Questionnaire