Contact Information

* Name

* Email

Insured's Information

* Name

* Address

* City

*Business Type/Entity

* State

* Zip code

* Driver's license #

* State of Issue:

(if requesting auto coverage)

* Phone

Fax

Production Details

* Production title

* Total production budget

* Type of production (short film, documentary, etc.), and a brief scenario

* Shoot location(s)

*Brief Synopsis:

Eligibility Questions

Yes No

Does the production include stunts, pyrotechnics, aircraft, boats, animals, race tracks, race courses, helicopters, motorbikes, snowmobiles, blanks, squibs, guns, Live Gangster Rap Music, Hard-Core/Soft-Core Porn ?

Yes No

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

Yes No

Are there any Unprotected or open heights above 15 feet?

Yes No

Are there any Employees supplied to or from an employee leasing operation (i.e. PEO)?

Yes No

Have there been any prior production insurance losses of any kind declared by the insured?

Coverages:

Coverages usually requested or required:

Property

- Equipment (list limit desired, if any)

Rented equipment value: (replacement cost value of all rented equip. you wish to insure)

$

Additional Coverages Available but usually not required:

Props/sets & wardrobe

$

- Check the following property coverage options desired, if any

Faulty stock &
negative film

none $25,000

Third party
property liability

none $250,000 $500,000 $1,000,000

Extra expense

none $10,000 $25,000

Liability Limits (check one)

None

1 million occurrence / 1 million aggregate

1 million occurrence / 2 million aggregate

2 million occurrence / 2 million aggregate

Rental Automobile Coverage

Yes No

Liability

Yes No

Physical damage

Coverage Dates

* Please list the dates
you need coverage for

How did you hear about
Gales Creek Insurance Services?

Is there any additional information you want the agent to be aware of?