Annual Production Insurance
Short Term Production Insurance
Special Events Insurance
Annual Production Insurance (DICE)
Named of Insured
Phone / Fax
Year Business Established
Description of Operations
Check YES if any production includes stunts, pyrotechnics, aircraft, boats, animals, race tracks, race courses, helicopters, motorbikes, snowmobiles, ATV’s, blanks, squibs, guns or other hazardous activities.
Check YES if any production includes Hard-Core or Soft-Core pornography.
Check YES if any production includes live gangster rap music.
Check YES if any production activities will take place outside of the US and Canada.
Check YES if any production includes unprotected or open heights above 15 feet.
Check YES if any employees are supplied to or from an employee leasing operation (i.e., PEO)
Check YES if you enter into any co-production arrangements.
Check YES if you have experienced any losses in the last 3 years.
If so, please describe here.
Years of Industry Experience
Annual Gross Production Cost
Maximum Budget per Production
Maximum Days per Production
Cities and States of primary shooting locations
Number of Employees
Number of Upcoming Productions (12 Months)
Date of Coverage
Occurrence / Aggregate Limit
Do your vendors your locations require special insurance?
Rented Equipment (camera, lighting, sound)
Rented Props, Sets, Wardrobes
Owned Equipment Props, Sets, Wardrobes
Negative Film, Videotape, Images
Third Party Property Damage
Check YES if you require Hired and Non-Owned Liability coverage.
Check YES if you require Hired and Non-Owned Physical Damage Liability coverage.
Check YES if you require Workers Compensation coverage.
Check YES if you require Travel Accident coverage.
Check YES if you would like a quote on discounted Payroll Services.