Please provide the following information:
Name of Production Company
  An Individual A Partnership
A Corporation Joint Venture Other
Phone
Mobile Phone
Address
FAX
Email
Contact Person
Companies FEIN #  and/or Contact's Driver's License#


Production Information
Title of Production
Describe planned project
Location of filming
Principal Photography dates From To
Special Hazards
Does project include? Watercraft, aircraft, motorbikes, snowmobiles, stunts, animals, pyrotechnics, chase scenes, guns, car races, mechanical devices, rap/hiphop/rock/metal, water activities, etc.
Yes No
Claims History Any prior event with any losses of any kind?
Yes No


Coverage

Coverage Provided

Limits of Liability

Deductibles

General Liability

$1 Mill. occ/$2 Mill. agg

None

Hired & Hired & Non-Owned

$2 Mill. occ/$2Mill. agg

None

Hired & Non-owned Auto
      Physical Damage

$125,000 per vehicle

$500,000 aggregate

10% of loss/$1,000 min.

$7,500 Maximum

Miscellaneous Equipment

Value of Equipment   $

Rented Owned
Territory US/Canada Worldwide
Type of Equipment
Props, Sets, & Wardrobe

    $

Third Party Damage

    $

Extra Expense

    $

Faulty Stock & Negative Film

    $

Worker Compensation  #Cast #Crew Shoot Days
 Pay Type:  W-2 1099
Deferred SAG Required
Term of Coverage From To

   

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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