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Contact Information
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* Name
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* Email
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Insured's Information
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* Name
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* Address
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* City
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*Business Type/Entity
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* State
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* Zip code
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* Driver's license #
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* State of Issue:
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(if requesting auto coverage)
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* Phone
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Fax
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Production Details
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ONLY ONE PRODUCTION CAN
BE INSURED PER POLICY
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* Production title
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* Total production budget
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* Type of production
(short film, documentary, etc.), and a brief scenario
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* Shoot location(s)
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Brief Synopsis:
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Eligibility Questions
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Yes
No
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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 ?
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Yes
No
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Is insurance coverage required outside the
U.S. and Canada?
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Yes
No
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Are there any Unprotected or open heights above 15 feet?
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Yes
No
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Are there any Employees supplied to or from an employee leasing operation (i.e. PEO)?
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Yes
No
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Have there been any prior production insurance
losses of any kind declared by the insured?
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Coverages: |
Please see our coverage definition on the previous page if you are unsure how to respond to the questions below,
or link directly by clicking
here (pdf)) |
Coverages usually requested or required:
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Property
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- Equipment
(list limit desired, if any)
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Rented equipment value: (replacement cost value of all rented equip. you wish to insure)
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$
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Additional Coverages Available but usually not required: |
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Props/sets & wardrobe
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$
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- Check the following property coverage
options desired, if any
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Faulty stock &
negative film
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none
$25,000
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Third party
property liability
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none
$250,000
$500,000
$1,000,000
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Extra expense
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none
$10,000
$25,000
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Liability Limits (check one)
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None
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1 million occurrence / 1 million aggregate
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1 million occurrence / 2 million aggregate
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2 million occurrence / 2 million aggregate
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Rental Automobile Coverage
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Yes
No
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Liability
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Yes
No
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Physical damage
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Coverage Dates
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* Please list the dates
you need coverage for
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How did you hear about
Gales Creek Insurance
Services?
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NOTE : If Workers Compensation coverage is obtained: Exclusion of coverage for officers and owners will apply
Exclusions of coverage for stunts and hazard activities will apply
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