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 Animals, Stunt, Precision Driving & Pyrotechnics Declaration Form

  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.

 

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Policyholder Information
Name of Company / Organization / Production:
Policy or Quote Number:
Full Name of Contact:
Number:

Email:

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Stunt, Animal, Driving or Pyrotechnic Scenes
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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

 

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):

Start and End Date:

to

 

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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