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  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
 
  • 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:
 
 
Signature (Please type your first and last name) Date
   
Title  
 

  

 
  

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