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  A Service of Supple-Merrill & Driscoll, Inc.

 

  

 

 Annual Events Application Instructions - Part I

  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.

  3. If you only have one event, complete the Single Event Insurance Application.

 

  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 Organization, Individual or Company:
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:

 

Underwriting
Operations:
Description of Business/Operations:
Estimated Number of Events Annually:
Any Loss in the Past 3 Years?:

 

Inland Marine

Equipment & Property Coverage

Rented Equipment, Props, Sets, Wardrobe:
Owned Equipment, Props, Sets, Wardrobe:
Rented Furs, Jewelry, Art & Antiques Coverage:

The Props, Sets & Wardrobe form provides up to $25,000 for furs, jewelry, arts, antiques coverage.  If a higher limit is required, include the additional limit under this coverage.  A schedule/appraisal for the item(s) will be required.

Extra Expense:
Third Party Property Damage:
Office Contents:
Business Income/Extra Expense:

Hired & Non-owned Auto Physical Damage:

Per Vehicle / Aggregate Limit

Rental Cost Reimbursement:

Covers the potential additional expense to rent similar equipment after a loss.

EDP:

Electronic Data Processing Equipment

Computers and related equipment, media, software. Software extra expense is automatically included up to 25% of the hardware limit.

Limited Computer Virus:

Attaches to EDP and provides limited coverage for computer viruses.

Accounts Receivable:
Valuable Papers and Records:
Money & Securities:

Waiver of Subrogation:

Coverage Extension Endorsement:

Valuable Papers

25,000

Signs 10,000
Outdoor Property 5,000 Per Item
25,000 Total
Electronic Media And Records 5,000
Debris Removal 50,000
Employee Dishonesty 5,000
Fire Department Service Charges 25,000
Fire Equipment Recharge 10,000
Pollutant Clean Up And Removal 15,000
Sewer Backup 25,000
Temporary Location 25,000
Accounts Receivable 25,000
Money & Securities 5,000

Worldwide Coverage:

 

Liability Policy
Occurrence/Aggregate Limit:
Fire Legal:
Medical Payments: 5,000

City/Other Special Certificates:

FilmL.A., Inc., NYC Mayor's Office of Film, Cities that require Special Wording on Certificates, etc.

Waiver of Subrogation:

Primary & Non-Contributory Wording Only if Required by Locations and Vendors.

Employee Benefits Liability:

Liquor Liability:

Host Liquor Only provides coverage under the General Liability form if the insured is not in the business of manufacturing, selling, serving, or furnishing alcoholic beverages. Full Liquor Coverage provides coverage under a separate liquor liability form. Full Liquor Coverage is not available in the following states NC, RI, VT.

Liquor Sales:

Abuse & Molestation:

Each Claim / Aggregate

 

Automobile
Hired/Non-Owned Liability:

Waiver of Subrogation:
Cost of Hire:

Mobile Studios and Film Trucks

Other Than Mobile Studios and Film Trucks

Number of Loaned or Donated Vehicles / Days:

# of Days

 

# of Vehicles 

 

Excess Liability

Occurrence/Aggregate Limit:

The Excess Liability is an additional layer of coverage above the General Liability, Auto and Employer's Liability.  Not that this Excess policy will only sit on top of risks insured through this program.

 

Spectators & Participants Medical

Available in all states except MD, MO, OH & WA

Accident Medical Benefit:

Death / Dismemberment / Medical

Covered Individuals:

 

Workers' Compensation

Available in: AL, AR, AZ, CA, CO, CT, DC, FL, GA, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MO, MN, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, PA, TN, SC, TX, UT, VA, VT, WV. In addition, for clients located in the above states, locations can now be added for operations that occur in the following 8 states: AK, DE, HI, MA, OR, RI, SD, WI.

Limits:

Waiver of Subrogation:

Primary & Non-Contributory Wording.

All States Endorsement (other than monopolistic states):

Included
Payroll Company (if any):

Payroll by Class Codes (if any)

# Full Time (W2) # Part Time (1099) Total Payroll
8742 - Salespersons - Outside:
8810 - Clerical Office Persons - NOC:
9154 - Crew:
9156 - Performers & Musicians:

Officers

Full Name Title

Schedule an Officer:

Workers compensation coverage is not provided for officers & owners. The title for at least one officer/owner must be entered in order to proceed. To capture the required information, edit and select the title for any existing contact, and/or enter a new officer/owner.

Locations:

Please provide complete street address for a location each state.

Although the workers compensation policy includes an all states endorsement, certain states may deny benefits if an address in that state is not scheduled on the policy.

To minimize the chance of a claim denial, please schedule a location in each state that the production will occur.  Only one location in each state is required.

Note: All productions shooting in New York are required by the NY Workers Comp Bureau to schedule a NY Location.

 

Notes

 

 

 

 

 

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