About You / Your BusinessLegal Business Name*Primary Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name:*Phone Number:*Email Address:* Year Business Established:*Description of Operations:*QualificationsWill any production include stunts, pyrotechnics, driving scenes, aircraft, boats, animals, race tracks, race courses, helicopters, motorbikes, snowmobiles, ATV's, blanks, squibs, guns or other hazardous activities?:* Yes No Will the production include any Hard-Core or Soft-Core pornography?:* Yes No Will the production include any live gangster rap music?:* Yes No Any unprotected or open heights above 15 feet?:* Yes No Any employee's supplied to or from an employee leasing operation (i.e. PEO)?:* Yes No Do you enter into any co-production arrangements?:* Yes No Has there been any losses or insurance claims in the past 3 years?:* Yes No Production DetailsGross Annual Production Costs:*Max Budget per Production:*Max Days per Production:*Cities and States of Primary Shooting Locations:*Number of Upcoming Projects:*Key Personnel Full Name:*Start Date of Coverage:* MM slash DD slash YYYY CoverageGeneral Liability (Occurrence / Aggregate Limit):*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5milRented Equipment (Total Replacement Value):*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000Rented Props, Sets & Wardrobe (Total Replacement Value):*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000Owned Equipment (Total Replacement Value):*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000Negative Film, Video Tape, Images:*ExcludedIncludedThird Party Property Damage:*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5milExtra Expense (Total Replacement Value):*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000Auto Liability - Hired and Non-Owned:*ExcludedIncludedAuto Physical Damage - Hired and Non-Owned:*ExcludedIncludedWorkers Compensation:*ExcludedIncludedIf Workers Compensation is included, please provide annual payroll for cast & crew:*Are you interested in receiving a quote for Errors & Omissions coverage?:* Yes No Would you like a quote for Employee Benefits? i.e. group health, disability, life insurance:* Yes No Preferred Broker*Select BrokerAlec RobertsNick PurselDanny ElisevichPete GybenJohn HartDaniel BanElizabeth BellNo PreferenceHow did you hear about us?:*GoogleReferralYelpOtherWho referred you?:*How?:CAPTCHA
