ProductionInsurance.com | Film School Insurance Application

Applicant Information

Name of Company / Organization:

Entity:

Full Name of Contact:

Number:

Fax:

Street Address:

City, State:

Zip/Postal Code:

Email:

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Underwriting Qualification Questions

Will any production include any of the following?

Stunts, Pyrotechnics, Aircraft, Boats, Animals, Race Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, ATV's, Blanks, Squibs, Guns, Hard-Core/Soft-Core Porn, or Other Hazardous Activities

If yes, please describe:

Is coverage required outside of the U.S. and Canada?

Confirm your understanding that student productions are covered only if student is currently enrolled at the film school and the project is a school sanctioned project:

Insurance History

Any Insurance Declined or Cancelled in the Past 3 Years?

Not applicable in MO

If yes, please describe:

Any prior production with any losses of any kind?

If yes, please describe:

Any Prior Insurance Coverage?

Film School Information
Year Film School Established:
School's Professor First and Last Name:
Number of Unique Students Enrolled During the Academic Year:
Maximum Number of Students Enrolled Concurrently:
Length of Academic Term:	In Weeks

Coverage Section

Type of Operations:

Annual Gross Production Cost:

Maximum Budget Per Production:

Maximum Days Per Production:

Rental Operations Revenue:

Shooting Locations:

Please Breakdown Number of Productions for Upcoming 12 Months by Category:

Category	Number

Effective Date:

Annual Policy Period

Inland Marine Property & Equipment Coverages
Rented Equipment:	Camera, Lighting, Sound, Etc.
Owned Equipment:
Rented Props, Sets & Wardrobe:
Negative Film, Videotape & Digitized Image:	Same Limit as Faulty Stock
Faulty Stock:
Extra Expense:
Third Party Property Damage:
Office Contents:
Rental Cost Reimbursement:	Covers the potential additional expense to rent similar equipment after a loss.
Waiver of Subrogation:

General Liability
Occurrence / Aggregate Limit:
Fire Legal:
Medical Payments:
Blanket Additional Insureds / Certificates of Insurance:	Included Blanket Additional Insureds allow for unlimited certificates to vendors and locations. City certificates, other special certs, and waivers of subrogation are picked up under their respective coverages.
City/Other Special Certificates:	Included FilmL.A., Inc., NYC Mayor's Office of Film, Cities that require Special Wording on Certificates, etc.
Waiver of Subrogation:	Included Primary & Non-Contributory Wording Occasionally Required by Locations.

Automobile - Hired & Non-Owned

Liability:

Physical Damage:

Occurrence / Aggregate

Deductible Options:

Cost to Hire Vehicles:

Number of Loaned or Donated Vehicles / Days:

# of Vehicles

# of Days

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

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Conditions and State Notifications above:


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