Please provide the following information: Name of Production Company Address Phone Mobile Phone FAX Email Website The Applicant is: An Individual A Partnership A Corporation (If the Applicant is a Corporation, please provide the following names) President Vice-Pres Secretary Treasurer Director Producer Production Mgr Director of Photo Producer's Prior Productions Title:  Ins. Carrier:  Title:  Ins. Carrier:  Previous Insurer Has the Applicant ever had any similar insurance declined or canceled in the past five (5) years? Yes No (If yes, explain) Has the Applicant had any previous losses over $50,000 (insured or uninsured) sustained by the Producer in the past five (5) years? Yes No (If yes, explain) Source of Financing Release or Distribution Organization Completion Bond Company (if none, please state so): Premium Audit Contact: Name: Phone: Title of Production: Productions are on: Feature Film for Theatrical Release Television Production Movie for Television Pilot Special Series Mini Series Other (Please Describe) Running Time (e.g. 30 min, 60 min, 90 min) Number of Series Episodes Type of Story (e.g. Drama, Comedy, Musical, Western): Storyline: Shooting Locations used during Principal Photography: Description of Location (Including City, State, Country) Period of time at each location From To Medical Facility: Describe arrangements made for First Aid and access to medical facilities and identify the person in charge and responsible for making arrangements: The Production involves : (check all that apply) Use of Animals Underwater Filming Motorcycles Special Vehicles Airborne Crafts Waterborne Crafts Railroad Cars or Equipment If any of the above are checked, describe in detail: Pyrotechnics (Explosions, fire) If checked, Supplemental Application Required Stunts or Hazardous Activities If checked, Supplemental Application Required Estimated costs of each Production or Episode a) Total Budget (including budgeted deferments): $ b) Story/Scenario; Screenplay & Re-writing & associated costs: $ c) Music, Sound Rights, Records and Royalties $ d) Gross Insurable Production Costs (a minus b & c) $ e) Post Production Costs: $ f) Net Insurable Production Costs (d minus e) $ g)Total Below The Line Costs $ Indicate if any of the following Optional items are to be insured: Story/Underlying Rights, Screenplay, Re-Writes $ Sound/Music Rights, Recording Costs $ Indirect Overhead $ Royalties $ Other (describe): $ Coverage Desired Extended Pre Production Cast Protection Do you want coverage for Extended Pre Production Cast Protection? Yes No (If yes, fill out below) Described Artist Role/Position Age Coverage Period Limit of Coverage: $ $ $ $ Total Limit of Coverage for all artists $ Are employment contracts "Pay or Play"? Yes No Do employment contracts contain "Tie-In" Arrangements? Yes No (If yes, please explain) Will any persons insured by the policy be involved in any hazardous activities during the term of the coverage? Yes No (If yes, please explain) Note: Please send copy of Contract or Deal Memo for each person to be insured Principal Photography Cast Protection Do you want coverage for Principal Photography Cast Protection? Yes No (If yes, fill out below) Described Artist Role/Position Age Stop Date? Yes No Yes No Yes No Yes No Please give particulars on any Stop Date question answered "Yes": Period of Pre Production: From: Until: Period of Principal Photography: From: Until: Limit of Coverage $ Deductible $ Coverage to be effective: Post Production Cast Protection Do you want coverage for Post Production Cast Protection? Yes No (If yes, fill out below) Described Artist Age Function or Responsibilities During Post Production Coverage Period Stop Date? Yes No Yes No Yes No Yes No Please give particulars on any Stop Date question answered "Yes": Period of Post Production: From: Until: Negative Film / Videotape Do you want coverage for Negative Film / Videotape? Yes No (If yes, fill out below) Name and Location of: Processing Laboratory: Storage Vaults: Editing Facility: Post Production Facility: Will original negative film material leave the above premises prior to the completion of a protection print? Yes No (If yes, please explain) Will the processing frequency during principal photography be on a daily basis? Yes No (If no, please explain) Film Transportation How will original negative material be transported from the filming location(s) to the processing laboratory? Film Type (e.g. 35mm, 70mm) Is Videotape used in lieu of negative film? Yes No Are Animation or Computer Generated Graphics used? Yes No (If yes, created or generated by whom?) Locations: Coverage to be effective: Limit of Coverage $ Faulty Stock, Camera, and Processing Do you want coverage for Faulty Stock, Camera, and Processing? Yes No (If yes, fill out below) Use of secondary market raw stock? Yes No Procedures: Will new experimental technology; cameras and/or equipment be used in the filming of the project? Yes No (If yes, please explain and provide names and qualifications of persons experienced in the technology:) Responsible Person(s): Name and position of person(s) responsible for conducting testing of cameras and raw stock: Name Position Limit of Coverage $ Deductible $ Props, Sets, and Wardrobe Do you want coverage for Props, Sets, and Wardrobe? Yes No (If yes, fill out below) Value of Owned $ (Please send schedule) Non-owned: $ (maximum value at any one time) List of Items List items with an insurable value in excess of $250,000 each: List any individual items of antiques, objects of art, rugs, furs, jewelry, precious or semi precious stones/metals/alloys in excess of $10,000: Responsible Person(s): Name and position of person(s) responsible for conducting testing of cameras and raw stock: Name Position Coverage Required From: Until: Limit of Coverage $ (owned and non-owned combined) Deductible $ (owned and non-owned combined) Miscellaneous Equipment You must have coverage for Miscellaneous Equipment... (Please fill out below) Value of Owned $ (Please send schedule) Non-owned: $ (maximum value at any one time) List of Items List any individual item(s) over $250,000: Miscellaneous Equipment Description: Brief description of protection of property on the insured's premises; (fire fighting equipment, watchman etc.) Equipment Location: Where will the equipment be kept during use? Return Location: Location to which the equipment will be returned when not in use: Responsible Person(s): Name and position of person(s) responsible for security and protection of equipment: Name Position Coverage Required From: Until: Limit of Coverage $ Deductible $ Third Party Property Damage You must have coverage for Third Party Property Damage... (Please fill out below) Third Party Property Description: Brief description of property or facilities to be used in connection with the production for which the Applicant may be responsible: (other than miscellaneous equipment, props, set, etc.) Coverage Required From: Until: Limit of Coverage $ Deductible $ Extra Expense Do you want coverage for Extra Expense? Yes No (as a result of loss of or damage to property or facilities used in connection with the production(s)) (if yes, please fill out below) Extra Expense Description: Estimated time needed to reconstruct destroyed key facilities, sets or scenery: Estimated time needed to replace lost or destroyed equipment: What other location or studio facilities would be immediately available? Coverage Required From: Until: Limit of Coverage $ Deductible $ Business Personal Property Do you want coverage for Business Personal Property? Yes No (If yes, please fill out below) Full Address of Premises/Location(s): Value of Owned $ (Please send schedule) Rented: $ (maximum value at any one time) Coverage Required From: Until: Limit of Coverage $ (owned and rented combined) Deductible $ (owned and rented combined) Money and Securities Do you want coverage for Money and Securities? Yes No (If yes, please fill out below) Maximum amount of cash on hand at any one location: $ Total cash on hand at all times at all locations: $ Responsible Person(s): Name and position of person(s) responsible for the handling and safekeeping of money and securities: Name Position Coverage Required From: Until: Limit of Coverage $ (for limits in excess of $50,000, complete supplemental application) Deductible $ Non Owned and Hired Auto Physical Damage Do you want coverage for Non Owned and Hired Auto Physical Damage? Yes No (If yes, please fill out below) Cost of Hire Mobile Studio Units and Film Trucks $ Other than above $ Percentage of Private Passenger Vehicles: Less than 50% of all vehicles Less than 25% of all vehicles Coverage Required From: Until: Limit of Coverage $ Deductible $ Other Coverage Do you want Other Coverage? Yes No (If yes, fill out below) Please Describe: Limit of Coverage $ Deductible $     Motion Picture Production Application (Film & TV) Producer's Package Application (DICE) Short-term Productions Short-term Special Event Errors & Omissions Liability (Radio, TV, Film Producers)

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