Motion Picture/Television Production EZQuote

30 Years Experience

ENTERTAINMENT PRO INSURANCE

Motion Picture, Television, Theatrical, Music, Broadcasting and Special Events

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HOME > APPLICATIONS > ONLINE FORMS > MOTION PICTURE/TELEVISION PRODUCTION

Step One:	Complete Form
Step Two:	Review and Submit
Step Three:	Finish

Welcome to Motion Picture/Television Production EZ-Quote from Entertainment Pro Insurance.

For fast service on your commercial accounts complete the form below and hit the ï¿½Step Twoï¿½ button. Your submission will be electronically delivered to the next available Commercial Lines Underwriter.

[ Required fields are bordered in red ]

CONTACT INFORMATION

Named Insured (Production Co. or Individual):	Named Insured is required!
Entity Type ( Indiv, LLC, LLP, Corp. LLC, Non-Profit, Other):	Entity type is required!
Physical Street Address (No P.O. Box):	Physical Street Address is required!
City:	City is required!
State, Zip Code:	State and Zip Cod is required!
Mailing Address (P.O. Box - okay):
Contact Person:	Contact Person is required!
Phone:	Phone is required!
Fax:	Fax is required!
E-mail Address:	Email address is required! Please enter a valid e-mail address!
Website Address:
Year Business Established?	Year Business Established is required!

QUALIFICATIONS QUESTIONS

Will production include any hard-core/soft-core pornography or live gangster rap music?

Yes

Is this a Co-Production?

Yes

Will any production activities take place outside of the U.S. and Canada?

Yes

How many productions are planned within the next 12 months?

Any unprotected or open heights above 15 feet or employees?

Yes

Any employees supplied to or from an employee leasing operation (i.e. PEO)?

Yes

Cast coverage to be included?

Yes

PRIOR COVERAGE / INSURANCE HISTORY

Previous Insurance Carrier and Policy Number:

Lines of Coverage:

Any Prior Losses / Claims?

Yes

Not Applicable

Insurance declined or cancelled in the past 3 years? (provide loss runs and /or details)

Yes

Not Applicable

PRODUCTION DETAILS

Production Title:

Type of Production (doc, commi, feature film, music video, etc):

Estimated Gross Production Coast/Total Project Budget:

Number of Episodes/Length (if applicable):

Policy Effective Date (Date Coverage Begins):

Production Start and End Dates
Pre-Production:
Principal Photography:
Post-Production:

Total Number of Shoot Days:

Shooting Location(s) - City & State:

Will the production include any stunts, pyrotechnics, aircraft, boats, animals, auto chase scenes, race tracks, helicopters, motorbikes, snowmobiles, ATV's, blanks, squibs, guns, over water scenes, or other hazardous activities?

Yes

Not Applicable

Brief Synopsis:

Will the production include unusual locations such as:
Public Utilities Premises Public Transportation Resort Arenas Marinas & Docks Offshore Oil Platforms

FOR MUSIC VIDEOS ONLY

Type of Music:
Decade of Music:
Artist Name:

PRODUCTION / KEY PERSONNEL

Listing of All Officers (to exclude from workers comp):

	First and Last Name	Date of Birth	Drivers License #/State
Executive Director
Producer
Director

COVERAGE OPTIONS

GENERAL LIABILITY

Limits of Liability:

1,000,000 Occ/ $1,000,000 Agg

1,000,000 Occ/ $2,000,000 Agg

2,000,000 Occ/ $2,000,000 Agg

3,000,000 Occ/ $3,000,000 Agg

4,000,000 Occ/ $4,000,000 Agg

5,000,000 Occ/ $5,000,000 Agg

Blanket Additional Insured:    Include   Exclude

City/Special Certificates (Permit/City):    Include   Exclude

Waiver of Subrogation:    Include   Exclude

AUTOMOBILE (Hired and Non-Owneed Auto)

Liability Limit:

1,000,000

2,000,000

Other

Other:

Physical Damage (per vehicle/aggregate limit):    Include   Exclude

Waiver of Subrogation:    Include   Exclude

Number of Vehicles/Trailers being rented:   Private Passenger    Trucks/Trailers

Number of Rental Days:

Estimated Cost of Hire/rental:

Inland Marine

Rented Equipment (Camera, Lighting, Sound, etc)	$
Rented Props, Sets & Wardrobe	$
Owned Equipment, Props, Sets, Wardrobe	$
Negative Film & Faulty Stock	$
Faulty Stock, Camera & Processing	$
Third Party Property Damage	$
Extra Expense	$
Office Equipment & Furniture/Contents	$
Electronic Data Processing (Computer HW/SW/Media)	$

WORKERS COMPENSATION

Workers Compensation Include Exclude

Waiver of Subrogation (only if required by contract) Include Exclude

If needed, please include contract with application

If "Include" is Selected:

	1.	What is the name of the entity requesting the waiver of subrogation?
	2.	What is their involvement in the event?

Number of Shoot Days:

Payroll Company Name (if any):

Payroll Classification	# Full-Time	# Part-Time	Volunteers	Total Payroll(W-2, 1099, Deferred, Other (Please identify)
Cast/Crew
Office/Clerical
Post Production
Others (Describe)

Listing of All Officers (to exclude from workers comp):

First Name	Last Name	Title/Position

ADDITIONAL COMMENTS:

INCLUDE the following items with completed application:

* Resumes/Bios of Key Personnel
* Copy of Script
* Shooting Schedule
* Budget

FOR AGENT USE ONLY

Insurance Agency Name:
Office Street Address:
City:
State, Zip Code:
Agent Contact Person:
Agent Contact Person Email:
Agent Contact Phone Number:
Agent Fax Number:

FRAUD STATEMENT

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.

(You will get a summary page to review before submitting)