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

 

  

 

 Short Term Production 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.

  3. Glossary of Terms.

 

  Program Information

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  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:

 

Qualification Questions
Will the production include any Hard-Core or Soft-Core pornography?
Will the production include any live gangster rap music?
Will any production activities take place outside of the U.S. and Canada?

Any unprotected or open heights above 15 feet?

Any employees supplied to or from an employee leasing operation (i.e. PEO)?

Confirm your understanding that if coverage is provided, only one production

will be covered by the policy(s) issued.

 

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?

 

Production Details

Title of Production:
Production Type:
Total Budget for Production:

Maximum eligible budget is 1,000,000.

For budgets over $1,000,000, please apply in Production Portfolio program.

Production Dates:

to

to

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If insuring rented equipment start with pick-up and end with drop-off day.

Synopsis:

Input a brief description of the shoot.

 

Filming Locations

Please choose the territories in which production activities will take place.

Country / State:

Additional Location Details:

 

Additional Questions

Will the production include any Stunts, Pyrotechnics, Aircraft, Boats, Animals, Race Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns?
 

 

Music Video Details

Only if Shoot is a Music Video

Music Category:
Music Decade:
Artist Name(s):

 

Key Production Contact

Foreign entities and/or foreign individuals shooting in the U.S. must have a permanent location in the U.S. or hire the services of a U.S. based producer or executive producer.
First Name:
Last Name:
Role:

At least 1 producer or executive producer must be scheduled on the production.

Drivers License:

State & Number

Country of Residence:

 

Stunt, Animal, Driving or Pyrotechnic Scenes

Click Here to Skip If None

Stunts
Please select the number of scenes for each type of Stunt scene.
Aerial Scenes:
Scenic shots from private or commercial airplanes, private of commercial helicopters, or aircraft other than airplanes or helicopters, that do not involve aerial acrobatics or other hazardous maneuvers.
Please indicate the number of each type of scene.
 
Exclusions:
Aircraft Liability, Workers' Compensation, aerial acrobatics or other hazardous maneuvers
Commercial Aircraft Shoot - Shoot from an airplane used in commercial aviation, powered either by jet or propeller.
Shoot from Other Jet Aircraft - Shoot from a jet airplane other than one used in commercial aviation, such as military aircraft, courier, or other non-commercial large plane.
Private Plane Shoot - Shoot from a private airplane powered either by jet or propeller.
Propeller Plane Shoot - Shoot from a propeller driven plane, not otherwise classified (such as a research plane, prototype plane, etc.)
Helicopter Shoot (Equipment<500,000) - Shoot from a helicopter where the value of the equipment taken aboard the helicopter is less than $500,000.
Helicopter Shoot (Equipment 500,000 to 1,000,000) - Shoot from a helicopter where the value of equipment taken aboard the helicopter is between $500,000 and $1,000,000.
Helicopter Shoot (Equipment>1,000,000) - Shoot from a helicopter where the value of equipment taken aboard the helicopter is greater than $1,000,000.
Hanglider Shoot - Scenic shots from a hanglider.
Parachute Shoot - Scenic shots from a parachuting or of a parachuting.
Hot Air Balloon Shoot Scenes - Scenic shots from a hat air balloon.
Unmanned Aircraft (Drones) - Owned Drone - Scenic shots from an unmanned aircraft (drone) owned by insured.  Use of an owned, unmanned aircraft (drone) for film production purposes with drone parameters of: Maximum weight 25 pounds; Maximum power rating 8 horsepower; Operations within the line of sight from the operator; Maximum height 400 feet.
Unmanned Aircraft (Drones) - Rented Drone - Scenic shots from an unmanned aircraft (drone) rented by insured from a third party.  Use of a rented, unmanned aircraft (drone) for film production purposes with drone parameters of: Maximum weight 25 pounds; Maximum power rating 8 horsepower; Operations within the line of sight from the operator; Maximum height 400 feet.

Scene Start and End Date:

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Falls:
Choreographed falls.
Please indicate the number of each type of scene.
 
Exclusions:
Workers' Compensation for falls above 3ft.
Falls (above 3ft) - Choreographed falls from heights above 3 feet.
Falls (3ft or less) - Choreographed falls from heights of 3 feet or less.

Scene Start and End Date:

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Fight Scenes - Choreographed:
Fight scenes that are choreographed, structured, and sequenced.
Please indicate the number of each type of scene.
 
Exclusions:
Workers' Compensation
No Physical Contact - Choreographed fight scenes that do not involve physical contact between actors.
Physical Contact (no weapons) - Choreographed fight scenes that involve physical contact between actors but do not involve any weapons.
Physical Contact (weapons) - Choreographed fight scenes that involve physical contact between actors and involve weapons.

Scene Start and End Date:

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Recreational Vehicles:
The use of recreational vehicles such as ATV's, Go Carts, mopeds, motorcycles, scooters, Segways, snowmobiles, and similar type vehicles.
Please indicate the number of each type of scene.
 
Exclusions:
Workers' Compensation
ATV's - Scenes involving the use of ATV's.
Go Cart - Scenes involving the use of Go Carts.
Moped - Scenes involving the use of mopeds.
Motorcycle - Scenes involving the use of motorcycles.
Scooter - Scenes involving the use of scooters.
Segway - Scenes involving the use of Segways.
Snowmobile - Scenes involving the use of snowmobiles.

Scene Start and End Date:

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Water Scenes:
Scenes that occur on water (other than scenes on boats - Use MovieBoat Program)
Please indicate the number of each type of scene.
 
Exclusions:
Workers' Compensation (except swimming pools)

 

Canoes - Scenes taking place on canoes in a body of water.
Close to Shore Shot - Scenes that take place in a body of water but relatively close to shore.
Inland Lakes - Scenes that take place on or in an inland lake. Workers' Compensation Ineligible.
Kayaks - Scenes taking place on kayaks in a body of water.
Surfing - Scenes that involve surfing.
Swimming Pools - Scenes taking place in swimming pools.

Scene Start and End Date:

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Weapons Scenes:
Scenes that involve prop guns, squibs, blanks, knives or other similar weapons.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

Blanks - Scenes that involve the firing of blanks from guns. A blank is a cartridge for a firearm that contains gunpowder but no bullet or shot. When fired, the blank makes a flash and an explosive sound.
Knives - Scenes involving the use of knives.
Prop Guns - Scenes involving guns that discharge other than squibs or blanks. Note that guns unable to fire are not considered stunt activities.
Squibs - Scenes that involve the use of squibs (small explosive devices).
Various use of Squibs, Blanks, Knives, Prop Guns - Scenes involving a combination use of squibs, blanks, knives and/or prop guns.

Scene Start and End Date:

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Pyrotechnics, Demolitions & Explosions
Please select the number of scenes for each type of Pyrotechnic, Demolition & Explosion scene.
Fireworks (Certificates Not Obtained):
These firework activities are to be utilized when a certificate of insurance is not obtained from the pyrotechnician.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

 

Minimal Risk Effect - Minimal risk effect will be 100% controlled, at least 500 feet away from the public and property. A permit from the fire department is not required. Actors and crew will not be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect.
Moderate Risk Effect - Moderate risk effect will be 100% controlled, at least 250 feet away from the public and property. A permit from the fire department is not required. Actors and/or crew may be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.
Medium Risk Effect - Medium risk effect will be 100% controlled, at least 100 feet away from the public and property. A permit is obtained from the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.
High Risk Effect - High risk effect is 100% controlled and takes place close to the public and/or property. A permit must be obtained and the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.

Scene Start and End Date:

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Fireworks (Certificates Obtained):
These firework activities are to be utilized when a certificate of insurance is obtained from the pyrotechnician.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

Minimal Risk Effect - A certificate of insurance is obtained from the pyrotechnician naming the production company as additional insured and loss payee.

Scene Start and End Date:

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Flashboxes:
Scene involving the use of a flashbox or similar device. A flashbox is a small box containing the socket into which a pyrotechnic cartridge is plugged. Also known as a flash pod.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

Flashboxes - Scene involving the use of a flashbox or similar device. A flashbox is a small box containing the socket into which a pyrotechnic cartridge is plugged. Also known as a flash pod.

Scene Start and End Date:

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Miscellaneous Pyrotechnic Effects (Certificates Not Obtained):
These pyrotechnic activities are to be utilized when a certificate of insurance is not obtained from the pyrotechnician.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

 

Minimal Risk Effect - Minimal risk effect will be 100% controlled, at least 500 feet away from the public and property. A permit from the fire department is not required. Actors and crew will not be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect.
Moderate Risk Effect - Moderate risk effect will be 100% controlled, at least 250 feet away from the public and property. A permit from the fire department is not required. Actors and/or crew may be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.
Medium Risk Effect - Medium risk effect will be 100% controlled, at least 100 feet away from the public and property. A permit is obtained from the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.
High Risk Effect - High risk effect is 100% controlled and takes place close to the public and/or property. A permit must be obtained and the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.

Scene Start and End Date:

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Miscellaneous Pyrotechnic Effects (Certificates Obtained):
These firework activities are to be utilized when a certificate of insurance is obtained from the pyrotechnician.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

Minimal Risk Effect - A certificate of insurance is obtained from the pyrotechnician naming the production company as additional insured and loss payee.

Scene Start and End Date:

to

Demolitions/Explosions (Certificates Not Obtained):
These demolition/explosion activities are to be utilized when a certificate of insurance is not obtained from the stunt coordinator.
Please indicate the number of each type of scene.

 

Minimal Risk Effect - Minimal risk effect will be 100% controlled, at least 500 feet away from the public and property. A permit from the fire department is not required. Actors and crew will not be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect.
Moderate Risk Effect - Moderate risk effect will be 100% controlled, at least 250 feet away from the public and property. A permit from the fire department is not required. Actors and/or crew may be near the effect. Licensed pyrotechnician is not required. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.
Medium Risk Effect - Medium risk effect will be 100% controlled, at least 100 feet away from the public and property. A permit is obtained from the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.
High Risk Effect - High risk effect is 100% controlled and takes place close to the public and/or property. A permit must be obtained and the fire department and the fire department will be present. Actors and/or crew may be near the effect. Licensed pyrotechnician is required to be present. Equipment cannot be in close proximity to the effect. Loss control and safety features must be provided.

Scene Start and End Date:

to

Demolitions/Explosions (Certificates Obtained):
These demolition/explosion activities are to be utilized when a certificate of insurance is obtained from the stunt coordinator.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

Minimal Risk Effect - A certificate of insurance is obtained from the pyrotechnician naming the production company as additional insured and loss payee.

Scene Start and End Date:

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Driving & Vehicle Effects
Please select the number of scenes for each type of Driving & Vehicle Effects Scene.
Precision Driving Scenes:
Scripted driving scenes that do not involve racing, chasing, skidding or collisions.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation, stunts, racing, chasing, skidding or collisions.

 

Public Roads Driving - Shoots occurring on public roads, not exceeding 80 MPH. No chase scenes, no speeding, no skidding.
Race Track Driving - Driving around a race track, not exceeding 80 MPH. No skidding or chasing. Single vehicles only.
Off-Road Driving - Driving on surfaces other than paved roads, not exceeding 80 MPH.  No skidding, racing or collisions.

Scene Start and End Date:

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Motorcycles:
No skidding, no collisions.
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation, stunts, racing, chasing, skidding or collisions.

 

Public Roads Driving - Shoots occurring on public roads, not exceeding 65 MPH. No chase scenes, no speeding, no skidding.
Race Track Driving - Driving around a race track, not exceeding 65 MPH. No skidding or chasing. Single vehicles only.
Off-Road Driving - Driving on surfaces other than paved roads, not exceeding 65 MPH.  No skidding, racing or collisions.

Scene Start and End Date:

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Chase Scenes:
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

 

Vehicle Chase Scenes - Scripted use of vehicles involved in racing or chase scenes.
Motorcycle Chase Scenes - Scripted use of motorcycles involved in racing or chase scenes.

Scene Start and End Date:

to

Vehicle Collisions:
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

 

Vehicle Collision Scenes - Choreographed, structured and sequenced collision of vehicle(s) and/or motorcycles.  No camera equipment mounted in vehicle or motorcycle.

Scene Start and End Date:

to

Vehicle Explosions:
Please indicate the number of each type of scene.
 
Exclusions:

Workers' Compensation

 

Vehicle Explosion Scenes (Minimal Risk Effect) - Minimal risk effect will be 100% controlled, at least 1000 feet away from the public and property. A permit must be obtained and the fire department will be present. Actors will not be in the vehicle and crew will be at least 100 feet away.
Vehicle Explosion Scenes (Moderate Risk Effect) - Moderate risk effect will be 100% controlled, at least 250 feet away from the public and property. A permit must be obtained and the fire department will be present. Actors will not be in the vehicle and crew will be at least 50 feet away.
Vehicle Explosion Scenes (Medium Risk Effect)  - Medium risk effect will be 100% controlled, at least 100 feet away from the public and property. A permit must be obtained and the fire department will be present. Actors will not be in the vehicle and crew will be at least 25 feet away.
Vehicle Explosion Scenes (High Risk Effect)  - High risk effect will be 100% controlled, in close proximity to the to public property. A permit must be obtained and the fire department will be present. Actors may be in the vehicle and crew will may be close to the vehicle.

Scene Start and End Date:

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Animal Coverage
Please select the number of scenes for each type of Animal scene.
Animal Scenes:
Scenes that involve Dogs, Farm Animals, Fish, Household Pets (Cats, Birds, Mammals, Reptiles), Water Mammals, Wild Animals, Wild Cats, Wild Birds, and Zoo Animals (Caged & No Contact).
 
Exclusions:

Workers' Compensation

 

Household Pets - Shoots that involve dogs, cats, birds, mammals, reptiles.
Farm Animals - Shoots that involve farm animals such as chickens, cows, goats, horses, lambs, pigs..
Fish Scenes - Shoots that involve domestic/pet fish, jelly fish, piranha, sharks.
Water Mammals - Shots from land of whales, dolphins and other water mammals.
Wild Animals - Wild animals not caged and/or for which there is contact with the animal.
Wild Birds - Scenes with wild birds such as ducks, flamingos, geese, swans.

Wild Cats - Wild cats not caged are ineligible.  If caged, see the category for Zoo Animals (Caged & No Contact).
Zoo Animals (Caged & No Contact) - Scenes of zoo animals.  Animals must be caged and there cannot be contact with the animals.

Scene Start and End Date:

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Animal Injury, Sickness & Death

Scheduling an animal provides coverage for injury and death. Sickness is included if a certificate of health by a duly licensed veterinarian is provided.

Animal Type(s):

To select multiple animals, please hold CTRL while selecting.

Name(s) of Animal:

Description of Use:

Age(s) in Years & Value(s):

Scene Start and End Date:

to

 

Inland Marine

Equipment & Property Coverage

Rented Equipment:

Owned Equipment:

Rented Props, Sets, Wardrobe:

Rented Furs, Jewelry, Art & Antiques Coverage:

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

Negative Film, Videotape, & Digitalized Image:
Faulty Stock:
Library Stock Coverage:

Expands the definition of negative film, videotape and digitalized image to include insured's original cut negative film of completed or released productions, duplicate negatives, completed video tapes or other related media.

Extra Expense:
Third Party Property Damage:
Office Contents:
Animal Extra Expense:
Rental Cost Reimbursement:

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

Accounts Receivable:
Valuable Papers and Records:
Money & Securities:

Civil Authority:

Extra expense due to the interruption, postponement or cancellation of an “insured production” that is directly caused by or results from the operation of civil authority. The operation of civil authority must prohibit access due to threat of or actual loss or damage to property allowing access to or use of facilities you occupy or intend to occupy in connection with an “insured production” during the term of coverage.

Agency and Talent Re-Shoot Costs:

Provides coverage for contractually obligated (yet unanticipated) talent, services or facilities costs incurred to reshoot the production after a covered loss.

Strikes or Civil Protest:

As a result of an officially sanctioned strike or civil protest, covers the loss due to the interruption, postponement or cancellation of the production.

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

Entertainment Enhancement Endorsement:

  Single Limit by Coverage Blanket Limit (100K)
Agency/Talent Re-Shoot Costs 25,000 / 1,500 Included
Power Supply Interruption 50,000 / 2,500 Included
Civil Authority 50,000 / 2,500 Included
Strikes or Civil Protest 25,000 / 1,500 Included
Library Stock Coverage 25,000 / 1,500 Included
Animal Physical Damage 25,000 / 1,500 Included
Animal Extra Expense 25,000 / 1,500 Included
Equipment Breakdown 25,000 / 1,500 Included
Blanket Coverage n/a 100,000 / 2,500

The figures above represent the Limit / Deductible.

Worldwide Coverage:

 

Cast Extra Expense

Cast Extra Expense:

Provides extra expense incurred in the completion of a production over and above the normal budgeted costs due to the death or disability (accident or sickness) or kidnapping of any scheduled artist. Cast coverage provides protection from pre-production through production and post-production. All artists must be scheduled in advance and medicals are required for sickness coverage. For coverage on an unscheduled basis, you may also include the 'covered person extension with sickness coverage'.

Covered Person Extension (without sickness):

Provides accidental injury or accidental death cast coverage without having to schedule artists. If sickness coverage is required for any artists, those artists must be scheduled (a reduced limit for sickness coverage on an unscheduled basis is available under the 'Covered Person Extension with Sickness' coverage). Expands the definition of covered person to include any person necessary for the completion of the insured production.

Covered Person Extension (with sickness):

 

Provides accidental injury, death and sickness coverage without having to schedule artists. Expands the definition of covered person to include any person necessary for the completion of the insured production.

Family Bereavement:

Expands cast coverage to provide for a bereavement period up to 5 days due to the death of an immediate family member.

 

Equipment Floater

Owned Equipment:

Unscheduled

 

General Liability
Occurrence / Aggregate Limit:
Fire Legal:
Medical Payments:
Blanket Additional Insured / Certificates of Insurance: Included

City/Other Special Certificates:

FilmL.A., Inc., NYC Mayor's Office of Film, Cities & Government Entities that require Special Wording on Certificates, etc.

Waiver of Subrogation:

Primary & Non-Contributory Wording Occasionally Required by Locations

Abuse & Molestation:

Each Claim / Aggregate

 

Automobile - Hired & Non-Owned
Physical Damage Limits:

Per Vehicle / Aggregate

Liability Limits:
Waiver of Subrogation:

Primary & Non-Contributory Wording

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

Will any bus or van be hired primarily for the purpose of transporting people?: Yes  No
  If yes, due to the inherent auto liability exposure of transporting people, information is required for drivers or any bus or van.
Full Name State Drivers License #

 

Excess Liability

Occurrence / Aggregate Limit:

The excess liability is an additional layer of coverage above the general liability, auto, and employers liability. Note that this excess policy will only sit on top of risks insured through Abacus programs.

 

Travel Accident

Guild Members, Non-Guild Members, Aggregate Limit:

Guild refers to employees who are part of a Guild, Trade Association or Labor Union.

The required Guild limit is $1,000,000. Non-Guild refers to all other employees.

 

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

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

9610 - Motion Picture Production
Payroll Company (if any):

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 in 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.

 

Notes

 

 

 

 

Terms and Conditions

Please carefully review the Terms and Conditions below:

  • 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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