Annual Production (DICE) Application
Contact Information
  • Name of Insured                        
  • Entity Type   Individual  Partnership   Joint Venture  LLC Corporation
  • Street Address                            
  • City                                            
  • State Zip   
  • Contact Person                          

  • Phone   Fax

  • Email                                          
  • Federal ID or Social Security #

Qualification Questions
Any: Stunts, Pyrotechnics, Aircraft, Boats, Animals, Race Tracks, Race Courses,
Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns, Live Rap Music?

 Yes No
Any insurance cancelled or declined in past 3 years (not applicable in Missouri) Yes No
If Yes, please explain
Any losses in past 3 years? Yes No

If Yes, total amount of losses? $
Production Details
Number of Production for upcoming 12 months by category
Animation Music Video
Commercial/Promotion/Sales Video Photography Shoot
Documentary/Interviews/Biography Pick up Shoot
Editing/Trailer Pre/Post Production
Educational/Instructional/Training PSA/Public Access Program
Feature Film Reality Based TV Show
Independent Feature SAG Production
Industrial/Corporate Video Short Film
Infomercial Spec Production
Miscellaneous Productions TV Pilot/Series/Specials

Total aggregate budget for all shoots
Average duration in days per production
Maximum budget per single shoot
Cities & States of shooting locations
Coverage Options

Effective Date of Coverage

Property Limit to Insure
  • Rented Equipment Limit
  • Owned Equipment Limit
  • Props, Sets, Wardrobe Limit
  • Negative Film/Faulty Stock
  • Third Party Property Damage
  • Extra Expense
  • Office Contents

General Liability
Occurrence/Aggregate Limit $1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $2,000,000
$3,000,000 / $3,000,000
$4,000,000 / $4,000,000
$5,000,000 / $5,000,000
Blanket Additional Insured/Certificates of Insurance

 Include Exclude
City Certificates Requiring Special Wording

 Include Exclude
Waiver of Subrogation

 Include Exclude

Hired & Non-Owned Auto
Liability $1,000,000.
$2,000,000.
$3,000,000.
$4,000,000.
$5,000,000.
Physical Damage $125,000 per vehicle, $500,000 aggregrate

 Include Exclude
Worker's Compensation
Number of Cast Crew Volunteers
Payroll W-2 1099 Deferred Other
Payroll Company Name (if any)
Officer 1 Name and Title
Officer 2 Name and Title

Authorized Agent: Date