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

 

  

 

 Multimedia Production E&O (Claims Made Basis) 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

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

Yes  No

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

Yes  No

 

Applicant Details

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. Any loss in the past 3 years?:

Yes  No

If Yes, please provide Policy Type, Carrier,

Policy #, Expiration and Premium above.

 

Representations

1.  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.

2.  Are You aware of any claim or threatened claim made against You or any of Your officers, members, or partners arising out of or related to the insurance sought, including title thereof?

Yes  No

If Yes, provide Policy Type, Date of

Loss, Description and Amount above.

3.  Applicant agrees to obtain from third parties from whom it will obtain services or content for the insurance sought written warranties and indemnification against claims arising out of the use of such services or content? I Agree  I Disagree
4.  Applicant agrees to use its best efforts to determine whether any content to be used in the named production or production library is protected by law and, and where necessary, to obtain from parties owning rights therein the right to use the same in connection with the insurance sought. I Agree  I Disagree
5.  Applicant agrees to use its best efforts to utilize clearance procedures which are the same or similar to those attached to this application. I Agree  I Disagree

 

Clearance, Licenses, Consents, and Releases

1. Has a title search for the Named Production been conducted by a title clearance service?

Yes  No

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

Yes  No

If Yes, please explain above.

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

Yes  No

If Yes, please explain above.

4. Have all performers who appear in the Named Production entered into a written performance agreement with the applicant related to their appearance?

Yes  No

5. Has the Applicant obtained a license, consent or release from those persons, animals or characters who appear in the Named Production without a written performance agreement? Yes  No

6. In the past three (3) years, have You been given notice of any potential infringement another party's intellectual property (IP) rights, including without limitation, copyright or trademark infringement?

Yes  No

If Yes, please explain above.

7. Did You screen the Named Production for the following possible offenses?

 

None

 Trademark Infringement

 Copyright Infringement

 False Light Claim

 Defamation

 Privacy Violations

 Violation of Rights of Publicity

Check All That Apply

8. If any of the aforementioned screenings were performed, were such screenings performed by, or under the supervision of, a qualified attorney?

Yes  No

 

Do Your Compliance Procedures include any of the following:

1. Training of employees regarding copyright, trademark, and defamation issues.

Yes  No

2. Do your requirements of freelancers, independent contractors, musicians, composers, or others who provide content include all of the following:

  1. To assign or license their rights to the content

  2. To warrant that their work does not violate another party's rights

  3. To indemnify you should an IP infringement claim be made against You

  4. To hold you harmless should an IP infringement claim be made against You

Yes  No

3. Acquisition of all necessary IP rights via licenses, consents, or releases

Yes  No
4. Trademark searches by employees Yes  No
5. Trademark searches by professional search firm Yes  No
6. Copyright searches by employees Yes  No
7. Copyright searches by professional search firm Yes  No
8. Clearance of performing, recording, and synchronization rights Yes  No
9. Were the requirements outlined above met with regards to the Insurance sought? Yes  No

 

Production Title and Type

Title:
Production Type:
Nature of Production:

Synopsis:

Input a brief description of the content.

 

Type of Work

Type of Work:

If 'Entirely Fictional but based on another's work:
Name of Author(s):
Title(s):
Date(s) of Publication:

 

Details of the Production

Total Budget:
Running Time: minutes
Number of Episodes and Length (series): episodes of each
Number of Weeks (series):
Initial Release or Air Date:

 

Distribution Area

 

 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.

 

Release Medium

How will the production be released?

Cable/Satellite/Wireless

DVD/Videotape

Will there be bonus material? Yes  No
Will bonus material use same clearance procedures as the rest of the production? Yes  No

 

Internet (Requires International Distribution Area above)
Radio
Television
Theatrical Release
Theatrical Stage
Other
Please Explain:

Select All That Apply

 

Key Production Personnel

Executive Producer
    First Name:
    Last Name
Producer
    First Name:
    Last Name:
Script Writer
    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: /
Limits:

Per Claim / Aggregate

Retention:
Rights Period Endorsement:

For policies on a claims made basis, the rights period extends the claims reporting period to 7 years from the policy effective date.

Title Coverage:

 

Title coverage may be included if a title search report is provided and approved by the insurance company.

Coverage Basis: Claims Made
Merchandising:

Merchandising provides coverage for the marketing of the media content during the policy period.

Additional Insured Endorsement:

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

Worldwide Coverage Territory: Included

 

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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