SHORT TERM FILM PRODUCTION INTAKE FORM

SHORT TERM PRODUCTION INSURANCE QUOTE INTAKE FORM

Step 1 of 6

PRIMARY INSURED INFORMATION

What's the formation type of your business?

What's the name of your LLC?

What's the name of your Corporation?

What's the full legal name of the individual?

What's the name of your Non-Profit?

What's the name of your Partnership?

What are the names of the businesses or individuals in the Joint Venture?

What's the name of the Trust?

Have You already been in Contact with one of Our Agents/Brokers?

YES

Which Agent/Broker has been Helping You?

MAILING ADDRESS (no P.O. Boxes) : This is Your Address, or the Business Address.

Street Address

City

State

Zip

PRIMARY CONTACT INFORMATION

First Name

Last Name

Phone Number

Email Address

Is the Main Contact Listed Previously an Owner, Executive, or Partner?

YES

Please list the name of at least one Owner, Executive, or Partner

Who should be listed as the Main Key Personnel

Our Underwriters Require the Name of at Least One Key Personnel to be Listed.

SAME AS THE MAIN CONTACT ALREADY LISTED

SAME AS THE OWNER / MEMBER / MANAGER ALREADY LISTED

I NEED TO ADD THIS INFORMATION

KEY PERSONNEL INFORMATION

First Name

Last Name

Film Production Role:

Our Underwriters do not need the License Information for the Quote, but this information will be Required Prior to Policy Issuance.

Leave Blank if You would prefer to hold of on Entering this Information.

Driver's License State:

License Number:

What is the Title of the Production?

What is the Production Type?

Is this an Indie Film, Feature Film, Music Video, Commercial, Documentary, etc...

What is the budget of this Production?

In other words, what is the total cost or budget of this Production?

When will the Production start?

When do you need Insurance to Start?

When will the Production End?

When do you need Insurance to End?

Check All Applicable Types of Workers that will be Involved in the PRODUCTION

CHECK ALL THAT APPLY

W-2 EMPLOYEES

GIG WORKERS & 1099's ONLY ( SUB CONTRACTORS )

SAG / UNION

N/A - JUST NEED TO HAVE WORKERS COMPENSATION LISTED ON THE CERTIFICATE OF INSURANCE

Total Number of CREW?

Total Number of CAST?

Please provide a synopsis of the Storyline

Feel Free to Copy & Paste, or Provide the Website of where the Storyline can be Reviewed...

Filming Locations (Select all States where Filming will Occur)

Country: State / Province:

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

YES

STUNT RELATED ACTIVITIES DETAIL

STUNT RELATED ACTIVITIES:

DATES WHEN ACTIVITY WILL OCCUR:

HOW MANY SCENES WILL BE FILMED ON THESE DAYS:

DESCRIBE IN DETAIL THIS ACTIVITY: