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 ProductionInsurance.com
  A Service of Supple-Merrill & Driscoll, Inc.

 

  

 

 Acquisition & Development E&O Application Instructions

  1. Please complete and submit this online application for a free, no-obligation quote.

  2. Please be sure to provide all required information in order to receive a quotation.  

 

  Program Information
This is a secure application.  Strong cryptography is implemented via the Secure Sockets Layer protocol.  Our Privacy Policy.

  PDF Application (Fillable)
 
 

( indicates required information)

Applicant Information
Name of Company / Organization:
Entity:
Full Name of Contact:
Number:
Fax:
Street Address:
City, State: ,
Zip/Postal Code:

Email:

We will never rent, sell, or share your email address.
Website:
Applicant Type:

 

General
Does the production involve any of the following: animation, pornographic materials, ride alongs, hidden cameras, pranks and consumer voting?

Yes  No
Will you be using a clearance attorney with at lease 5 years of relevant media law experience?

Yes  No

 

Operation Details
Operations:  
Description of Business/Operations:
Number of Employees:

 

Insurance History

Any insurance declined, cancelled or non-renewed that provided the same or similar coverage s the insurance sought?

Yes  No

Not Applicable in MO

Any prior E&O coverage?:

Yes  No

If Yes, please provide Policy Type, Carrier, Policy #, Expiration and Premium above.

Are You aware of any claims or legal proceedings made or commenced against You or any of Your officers, members, or partners within the last five (5) years for: (1) invasion of privacy or false light; (2) IP Infringement; (3) defamation; or (4) breach of contract arising out of the alleged submission of any ideas, story line, or script?

Yes  No

If Yes, provide Policy Type, Date of Loss, Description and Amount above.

 

Development of Projects

Do you accept unsolicited submissions outside of agents or lawyers submissions?

Yes  No

If Yes, please provide unsolicited submissions procedures above.

What percentage of projects that you acquire for development do you also produce post principle photography?

Is the production based on an underlying work?

Yes  No

If Yes,
a. Have copyright reports been obtained? Yes  No
b. Are there any ambiguities, gaps or problems in the chain of title? Yes  No
c. Has the chain of title of all works on which the production is based been thoroughly investigated and cleared back to the original copyright owners to determine that all grants or transfers in the chain of title permit you to assign or sublicense the material as incorporated in your production Yes  No

If No,
a. Are you aware of any similar format or concept? Yes  No
b. Has your attorney confirmed that they are satisfied you can safely proceed with your exploitation of the work? Yes  No
c. Has any similar format or similar material been submitted to you at any time?

Yes  No

 

Contractual Provisions for Third Party Acquired Productions

Does the applicant obtain full indemnities from sellers against liability arising out of the distribution, exhibition or other use of the productions acquired?

Yes  No

Does the applicant require the seller to warrant that each production has producers errors and omissions insurance?

Yes  No

 

Contractual Provisions for Productions Licensed for Distribution

Does the applicant obtain full indemnities from the licensor against any liability arising out of the distribution, exhibition or other use of the productions licensed for distribution?

Yes  No

Does the applicant require the licensor to warrant that each production has current producers errors and omissions?

Yes  No

 

Claims Details

Have you suffered any loss or has any claim, whether successful or not, ever been made against you?

Yes  No

If Yes, please explain below.

Are you aware of any matter which is likely to lead to you suffering a loss or claim or a claim being made against you?

Yes  No

If Yes, please explain below.

 

Material Information

Is there any other information which may be material to our consideration of your application for insurance (If you have any doubt over whether something is relevant, please let us have details).

Yes  No

If Yes, please explain below.

 

Library Details
Do you have a film library?

Yes  No

If Yes,

a. How many titles in your library?

b. What percentage of your library titles have you produced or acquired?

c. What percentage of your library titles do you license for distribution and do not own the rights?

d. What percentage of your library titles were first exhibited prior to 1978?

e. Have you purchased producer's Errors & Omissions coverage for all titles produced by you in your library?

Yes  No

f. Are any titles in the library reality, documentaries, animation or quiz/game shows?

Yes  No

 

Distribution Details
 

Estimated gross annual revenues from

Current Year

Prior Year

All Sources:

Distribution:

 

 

 

 

Third Parties

Input third parties to whom you intend to provide productions to in the coming year. (Optional)

 

Name of Third Party

Types of Productions

1. 

2. 

3. 

4. 

 

 

Estimated # of productions to be distributed annually which are:
 
Feature Film (for theatrical release)
Films for Television
Films for DVD only
Television Series
Reality Television
Webisodes/Internet Productions

Docu-dramas

Documentaries

Animation

Quiz/Game Shows

Other

 

 

Distribution Territory
 

 Local

 90% of distribution within local area (population less than 100,000).
   Metro 90% of distribution within larger metro area (population 100,000 or greater).
   Regional 90% of distribution within 2 to 6 states.
   National 90% of distribution within the nation.
   International Greater than 10% of distribution outside the nation.

 

Key Personnel
Executive Producer
    First Name:
    Last Name
Producer
    First Name:
    Last Name:

 

Legal Information
Firm Name:
Attorney Name:
Street:
City:
Country:
City, State: ,
Zip:
Phone:
Fax:
Email:

 

Contractual Provisions for Third Party Acquired Productions

Does the applicant’s attorney approve as adequate the steps taken for clearance procedures in connection with the acquisition of each production?

Yes  No

View Clearance Procedures

 

Additional Insureds

The Additional Insureds is used to capture the distributors, broadcasters, investors, talent and other entities required to be named as additional insured under the policy. Certificates of insurance can be issued for the additional interests scheduled. Please note that the policy holder should not be scheduled as an additional interest.

 

 

 

Coverage Options
Effective Date / Policy Term: / 
Per Claim / Aggregate:
Retention:
Coverage Basis:

The Coverage Basis may be selected as either occurrence or claims made (depending on the program and state jurisdiction). In addition, certain programs may allow for Rights Period Endorsement (availability would be indicated inside the coverage dropdown
Additional Insured Endorsement:

Select Additional Insureds if certificates of insurance are required for distributors, studios, investors, talent and/or others.

 

Notes

 

 

 

  

Terms and Conditions
 
  • I represent that this application form has been completed after proper inquiry and, based on this inquiry, I represent the application contents are true, accurate, and not misleading.
  • I represent that I understand and agree that if any of the contents of this application are intentionally untrue, inaccurate, or misleading, in any material respect, or if I fail to notify the insurance company of additional information that might render the contents of this application untrue, inaccurate, or misleading, in any material respect, then the insurance company is entitled to rescind any policy issued pursuant to this application.
  • 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 civil penalties.
  • I represent that I understand and agree that this application and all materials submitted in connection with this application are incorporated into and form the basis of any policy issued by the insurance company pursuant to this application.
  • I represent that by signing this application I am representing that I am duly authorized to execute insurance contracts on behalf of the entity applying for this coverage and that all representations (whether verbal or written) made in connection with this application are made on behalf of and shall be fully binding upon such entity.
  • A quotation received is not binding on the Insurer in any way. 
  • By clicking 'Submit Application' you are not agreeing to purchase coverage.  If terms can be offered you will receive a free, no-obligation insurance quotation via email.  All quotes require underwriter’s approval and payment prior to binding.  Please read all exclusions indicated on the quotation.
  • Please note that once coverage is bound, the policy cannot be cancelled.
  • The insurance quotation will be based solely on the coverages and limits selected on this application.

  • Please ask your Supple-Merrill & Driscoll, Inc.. representative to further explain coverage details, exclusions (including stunts and/or other hazardous activities), limits or other provisions of any insurance policy, or to request a sample policy form.

 

State Notifications

 

NOTICE TO ALASKA RESIDENT APPLICANTS: A person who knowingly and with the intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information is guilty of a felony.

NOTICE TO ARKANSAS RESIDENT APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and subject to fines and confinement in prison.

NOTICE TO CALIFORNIA RESIDENT APPLICANTS: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in prison. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NOTICE TO COLORADO RESIDENT APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DELAWARE RESIDENT APPLICANTS: Any person who knowingly, and with the intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.  

NOTICE TO DISTRICT OF COLUMBIA RESIDENT APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, any insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA RESIDENT APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a false statement of claim or an application) containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO HAWAII RESIDENT APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punish able by fines, imprisonment or both.

NOTICE TO IDAHO RESIDENT APPLICANTS: Any person who knowingly, and with the intent to defraud or deceive any false, incomplete or misleading information is guilty of a felony.

NOTICE TO INDIANA RESIDENT APPLICANTS: A person who knowingly and with the intent to defraud an insurer files a statement of claims containing any false, incomplete or misleading information commits a felony.

NOTICE TO KENTUCKY RESIDENT APPLICANTS: Any person who knowingly and with the intent to defraud an insurance company or other person files an application for insurance or statement of claim 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.

NOTICE TO LOUISIANA, MAINE AND TENNESSEE RESIDENT APPLICANTS: Any person who knowingly and with the intent to defraud any insurance company or another person, files a statement of claim contain 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, subject to criminal prosecution and civil penalties. Insurance benefits may also be denied.

NOTICE TO MINNESOTA RESIDENT APPLICANTS: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEBRASKA RESIDENT APPLICANTS: Any person who knowingly presents false information in an application for insurance or viatical settlement contract is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO NEVADA RESIDENT APPLICANTS: Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

NOTICE TO NEW HAMPSHIRE RESIDENT APPLICANTS: Any person who, with the purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NOTICE TO NEW JERSEY RESIDENT APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO RESIDENT APPLICANTS: Any person who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK RESIDENT APPLICANTS: Any persons who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NOTICE TO OHIO RESIDENT APPLICANTS: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA RESIDENT APPLICANTS: WARNING: Any person who knowingly and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON RESIDENT APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO PENNSYLVANIA RESIDENT APPLICANTS: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties.

NOTICE TO UTAH RESIDENT APPLICANTS: For your protection, Utah law requires the following to be included in this application: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO VIRGINIA RESIDENT APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO WASHINGTON RESIDENT APPLICANTS: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO WEST VIRGINIA RESIDENT APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison

 

Type your name below, to indicate that you have read and accepted the Terms,

Conditions and State Notifications above:
 
 
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