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

 

  

 

 Blanket DICE 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
Confirm your understanding that the blanket DICE E&O policy covers only the following types of productions: commercials, industrial, educational, audio or audio-visual presentations, musical videos (only if your client(s) has agreed to fully indemnify you for all featured music), short films (produced by you for others).

Yes  No

Will you be using a clearance attorney with at lease 5 years of relevant media law experience?

Yes  No

 

Operations

Operations:

 

Description of Operations:

Number of Employees:

 

Insurance History

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

 

Yes  No

If Yes, please provide explain. Not applicable in MO.

2. Any prior E&O coverage?:

Yes  No

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

3. 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.

 

Types of Productions

Are any productions based on an underlying works? Yes  No

If Yes,

  1. Have copyright reports been obtained?
Yes  No
  1. Are there any ambiguities, gaps or problems in the chain of title?
Yes  No
  1. 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,

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

 

Clearance Procedures

Is the name or likeness of any actual living person used, portrayed or identifiable in any Production?

  1. If Yes, will necessary permissions be obtained prior to first airing, distribution or public display of the production?

Yes  No

 

Yes  No

Is the name or likeness of any actual deceased person used, portrayed or identifiable in any Production?

  1. If Yes, will necessary permissions be obtained from personal representatives, heirs or estates prior to first airing, distribution, or public display of the production?

Yes  No

 

Yes  No

Do you always obtain title and trademark reports from a recognized agency and have this confirmed as satisfactory by a suitably qualified attorney?

Yes  No

Have you obtained a written agreement from all performers or persons appearing in your production consenting to their appearance?

Yes  No

Are the following musical rights always obtained from the composer and/or cleared with the owners of pre-existing music and/or

recordings:

  • Recording and synchronization

  • Performing rights?

  • Right to distribute for all forms of distribution contemplated (home video, etc.)

Yes  No

Have you or any of your agents been unable to obtain or been refused an agreement or release after having:

  • Negotiated for any rights in literary, musical or other materials?

  • Negotiated for release from any persons in respect of any material incorporated in the production?

Yes  No

 

Licenses, Releases, Consents

Will any film clips, TV clips or photographs be used in the

productions?

Yes  No

If Yes,

  1. Have all licenses and consents been obtained from the copyright owner without restriction and are you authorized to assign or sublicense the licensed materials as incorporated in your production?
Yes  No
  1. Do you have the authorization of any person or entity depicted in the film clip, TV clip or photograph to use their depiction in your production and to assign or sublicense that depiction in your production?
Yes  No

 

Legal Procedures

A client contract is used for all projects and contract is approved by the client.

Yes  No

Where a production is based upon an original format with which you are already familiar or where it is based upon a similar format or similar material that has been previously submitted to you, do you refer to your attorney for confirmation that can safely proceed with your exploitation of the work?

Yes  No

Have you suffered any loss or has any claim, whether successful or not, ever been made against you that would be covered by this insurance?

Yes  No

If Yes, please provide details below including the date of each

claim or loss, the amount of the claim and any remedial action taken.

Are you aware of any problem which is likely to lead to you suffering a loss or a claim being made against you that would be covered by this insurance?

Yes  No

If Yes, please provide details of each problem above.

It is understood and agreed that with respect to the above questions if such knowledge of information exists, any claim or action arising there from is excluded from this proposed coverage.

Yes  No

 

Production Details

 

  Current Year Prior Year
 

Revenues

Average Production Budget

 

 

 

 

 

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. 

 

 

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.

 

General

Do you specialize in any types of productions?

Yes  No

If Yes, please provide details of each problem above.

 

Key Personnel

Executive Producer
    First Name:
    Last Name
Producer
    First Name:
    Last Name:

 

Legal Information

Do you utilize a media attorney?

Yes  No

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

 

Legal Procedures

Have you and your attorney read and agreed to exercise due diligence to insure that the ‘Clearance Procedures’ attached are followed?

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:

Include Additional Insured Endorsement if certificates of insurance are required for distributors, studios, investors, talent and/or others.

 

Notes

 

 

 

  

Terms and Conditions

Please carefully review the Terms and Conditions below:

  • The terms specified herein are only an indication of coverage.

  • Please read all exclusions indicated on quotation.

  • The quotation received is not binding on the Insurer in any way.

  • By clicking 'Submit Application' you are not agreeing to purchase coverage.  Via email, you will receive a free, no-obligation insurance quotation.

  • 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.
  • 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 explain coverage details, exclusions, limits or other provisions of any insurance policy.

Type your name below, to indicate that you have read

and accepted the Terms and Conditions above:

 

  

 

  

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