Multimedia Production E&O
(Claims Made Basis) Application
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.
PDF Application (Fillable)
indicates required information)
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We will never rent, sell, or
share your email address.
1. Does the
production involve any of the following: pornographic
materials, ride alongs, hidden cameras, pranks and consumer voting?
2. Will you be
using a clearance attorney with at lease 5 years of relevant media
1. Any insurance
declined, cancelled or non-renewed that provided the same or similar
coverage s the insurance sought?
If Yes, please provide explain. Not applicable in MO.
2. Any prior E&O coverage?:
If Yes, please provide Policy Type, Carrier,
Policy #, Expiration and Premium above.
loss in the past 3 years?:
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?
If Yes, provide
Policy Type, Date of
Loss, Description and Amount
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?
1. Has a title search for the Named
Production been conducted by a title clearance service?
2. Is the name or likeness of any actual living person used, portrayed
or identifiable in the Named Production?
If Yes, please explain above.
3. Is the name or likeness of any actual deceased person used, portrayed
or identifiable in the Named Production?
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
7. Did You screen the Named Production for the following possible
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?
Compliance Procedures include any of the following:
1. Training of employees regarding
copyright, trademark, and defamation issues.
2. Do your requirements of freelancers,
independent contractors, musicians, composers, or others who provide
content include all of the following:
To assign or license their
rights to the content
To warrant that their work
does not violate another party's rights
To indemnify you should an
IP infringement claim be made against You
To hold you harmless should
an IP infringement claim be made against You
Acquisition of all necessary IP rights
via licenses, consents, or releases
Title and Type
Input a brief description of the content.
Type of Work:
< select type of work>
Entirely fictional and original
Entirely fictional but based on another's work
Entirely fictional but inspired by actual events
Portrayal of actual events with original fictionalization
True portrayal of actual events
Details of the Production
How will the production be
Select All That Apply
utilize a media attorney?
Have you and your attorney read and agreed to exercise due diligence to
insure that the ‘Clearance Procedures’ attached are followed?
View Clearance Procedures
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.
Please include complete name and address for each Additional Insured:
1,000,000 / 1,000,000
1,000,000 / 2,000,000
1,000,000 / 3,000,000
1,000,000 / 5,000,000
2,000,000 / 2,000,000
2,000,000 / 4,000,000
2,000,000 / 5,000,000
3,000,000 / 3,000,000
3,000,000 / 5,000,000
4,000,000 / 4,000,000
5,000,000 / 5,000,000
Per Claim / Aggregate
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 may be included if a title search
report is provided and approved by the insurance company.
Merchandising provides coverage for
the marketing of the media content during the policy period.
Include Additional Insured
Endorsement if certificates of insurance are required
for distributors, studios, investors, talent and/or others.
Please carefully review the
Terms and Conditions below:
The terms specified herein are
only an indication of coverage.
read all exclusions indicated on quotation.
The quotation received is not
binding on the Insurer in any way.
clicking 'Submit Application' you are not
agreeing to purchase coverage. Via email, you will
receive a free, no-obligation insurance quotation.
that once coverage is bound, the policy cannot be cancelled.
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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