ProductionInsurance.com | Theatrical, Sporting & Special Event Application

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:
Applicant Type:

Qualification Questions
Does the event include any of the following? Stunts, Pyrotechnics, Aircraft, Hazardous Activities, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production, Live Rap or Hip-Hop Performances
The event will take place in the United State or Canada?
Confirm on one event can be covered per policy:
Any bounce houses or inflatables?	If yes, certificates of insurance from vendor are required.
Any private armed security?	(i.e. armed security that work exclusively for you under your employ)

Insurance History

Any insurance declined or cancelled in the past 3 years?

Any loss in the past 3 years?

Not applicable in MO

If Yes, please describe.

Any prior insurance coverage?

Event Details
Event Category:
Event Name:
Event Description:
Event Cost/Budget:	How much the event is costing to put on.
If a Music Festival, How Many Bands:
Artist(s) / Band(s):	Required if live music or a concert event.
Music Category (If any):	Hold Ctrl to select multiple categories.

Dates
Setup Date(s):	to (if any) The period before the event to arrange. Attendees will not be present during the setup. Select up to 7 days at no additional premium.
Event Date(s):	to (required) The duration the actual event will take place (not including setup and teardown). Attendees will be present during the actual event.
Tear Down Date(s):	to (if any) The period to dismantle after the event. Attendees will not be present during tear down. Select up to 7 days at no additional premium.
Event Hours:	to
Total Number of Event Days:	Do not include Setup and Tear Down dates.

Venue Details Location Where Event Takes Place - Only One Venue Per Policy
Venue Name:
Address:
City:
State/Territory:
Zip:
Event Location:
Private Armed Security Guards:	Private Armed Security Guards make the event ineligible for this program.

Vendor's Liability Option to Extend Coverage to Vendors
The policyholder is automatically covered for claims arising out of the vendors activities (unless the activities are excluded on the policy). By inputting the information below and providing a schedule subject to underwriter's review, for an additional premium the vendors coverage will be extended to allow for vendors to be covered should they be named in a suit.
# of Exhibitors (no sales):
# of Concessionaires (non-food sales):
# of Concessionaires (food sales):
# of Attractions (performers):

Attendees

Average Daily Attendees:

Average Daily Participants:

(If any)

Sporting / Theatrical Participants

Inland Marine

Equipment & Property Coverage

Equipment, Props, Sets, Wardrobe (Rented):

Equipment, Props, Sets, Wardrobe (Owned):

Rented Furs, Jewelry, Art & Antiques Coverage:

The Props, Sets & Wardrobe form provides up to $25,000 for furs, jewelry, arts, antiques coverage. If a higher limit is required, include the additional limit under this coverage. A schedule/appraisal for the item(s) will be required.

Extra Expense:

Third Party Property Damage:

Hired & Non-owned Auto Physical Damage:

Per Vehicle / Aggregate Limit

Rental Cost Reimbursement:

Covers the potential additional expense to rent similar equipment after a loss.

Waiver of Subrogation:

Coverage Extension Endorsement:

Valuable Papers	25,000
Signs	10,000
Outdoor Property	5,000 Per Item 25,000 Total
Electronic Media And Records	5,000
Debris Removal	50,000
Employee Dishonesty	5,000
Fire Department Service Charges	25,000
Fire Equipment Recharge	10,000
Pollutant Clean Up And Removal	15,000
Sewer Backup	25,000
Temporary Location	25,000
Accounts Receivable	25,000
Money & Securities	5,000

General Liability
Occurrence/Aggregate Limit:
Fire Legal:
Medical Payments:
Certificates of Insurance / Blanket Additional Insureds:	Included Blanket Additional Insureds allow for unlimited certificates to vendors and locations. City certificates, other special certificates, and Waivers of Subrogation are picked-up under their respective coverages.
City / Other Special Certificates:	FilmL.A., Inc., NYC Mayor's Office of Film, Cities that require Special Wording on Certificates, etc.
Waiver of Subrogation:	Primary & Non-Contributory Wording Only if Required by Locations and Vendors.
Liquor Liability:	Host Liquor Only provides coverage under the General Liability form if the insured is not in the business of manufacturing, selling, serving, or furnishing alcoholic beverages. Full Liquor Coverage provides coverage under a separate liquor liability form.
Liquor Sales:
Percentage of Attendees Estimated to Consume Alcohol:
Abuse & Molestation (Each Claim/Aggregate):
Abusive Act Alleged Participant (Each Claim/Aggregate):
Participant Legal Liability (Each Claim/Aggregate):	Participants Legal Liability provides coverage for the insured for damages due to bodily injury or property damage sustained by participants at a covered event. Coverage is not extended for suits brought by one participant against another. This coverage requires that signed waivers be obtained from all participants. Please review policy for complete terms and conditions.

Automobile
Hired / Non-Owned Liability:
Waiver of Subrogation:
Will any bus or van be hired primarily for the purpose of transporting people?:	Yes No
Hired & Non-Owned Auto Liability is rated based upon the cost to rent vehicles, duration of rentals and the number of vehicles that will be rented.
Number of Loaned or Donated Vehicles / Days:	# of Days	# of Vehicles
Cost of Hire:	Mobile Studios and Film Trucks	Other Than Mobile Studios and Film Trucks

Excess Liability

Occurrence / Aggregate Limit:

The Excess Liability is an additional layer of coverage above the General Liability, Auto and Employer's Liability. Not that this Excess policy will only sit on top of risks insured through this program.

Workers' Compensation

Available in: AL, AR, AZ, CA, CO, CT, DC, FL, GA, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MO, MN, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, PA, TN, SC, TX, UT, VA, VT, WV.

In addition, for clients located in the above states, locations can now be added for operations that occur in the following 8 states: AK, DE, HI, MA, OR, RI, SD, WI.

Limits:

Waiver of Subrogation:

Primary & Non-Contributory Wording

All States Endorsement (other than monopolistic states):

Included

Payroll Company:

If Any

Identification Number:

An identification number is required when binding Workers' Compensation coverage.

Payroll by Class Codes (if any)

# Full Time Employees

Over 25 hours/week

# Part Time Employees

Under 25 hours/week

Payroll

Total W-2, 1099, & Deferred

8742 - Salespersons - Outside:

8810 - Clerical Office Persons - NOC:

9154 - Crew:

9156 - Performers & Musicians:

Officers

Full Name

Title

Schedule an Officer:

Workers compensation coverage is not provided for officers & owners. The title for at least one officer/owner must be entered in order to proceed. To capture the required information, edit and select the title for any existing contact, and/or enter a new officer/owner.

Locations:

Please provide complete street address for a location each state.

Although the workers compensation policy includes an all states endorsement, certain states may deny benefits if an address in that state is not scheduled on the policy.

To minimize the chance of a claim denial, please schedule a location in each state that the production will occur. Only one location in each state is required.

Note: All productions shooting in New York are required by the NY Workers Comp Bureau to schedule a NY Location.

Spectators & Participants Medical

Available in all states except MD, MO, OH & WA

Accident Medical Benefit:

Death / Dismemberment / Medical

Covered Individuals:

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


Home \| About Us \| Client Services \| Sitemap \| Claims \| Blog \| Contact Us
Productions \| Entertainment Services \| Events \| Floaters \| Errors & Omissions \| Instant Quotes

ProductionInsurance.com is the entertainment division of Supple-Merrill & Driscoll, Inc. California License 0517777.
Copyright © 2022. All rights reserved. Terms of Use \| Privacy Policy


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