Short Term Application
Contact Information
  • Name of Insured                        
  • Entity Type                                 
  • Street Address                            
  • City                                            
  • State & Zip                                  Zip
  • Contact Person                          
  • Phone                                        
  • Fax                                          
  • Email                                         
  • Federal ID / Social Security #       

Qualification Questions
IMPORTANT :  To provide an acccurate and quick quote please answer ALL questions
  • Any: Stunts, Pytotechnics, Aircraft, Boats, Animals, Race Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns, Rap Music?                                                    Yes                     No

  • Is coverage required outside of the U.S. and Canada?              Yes                     No
  • Any prior production with any losses of any kind?                     Yes                     No
Production Details
Please answer ALL questions
  • Type of Production


  • Title of Production
  • Budget (Gross Production Costs)
  • Brief Description / Synopsis of Shoot
  • Cities and States of Shooting Locations
  • Coverage Dates of the Production
  • Producer's Name

  • Driver's License # Issuing State

  • Country of Residence

For Music Videos Only
Please answer only if production is Music Video
  • Type of Music
  • Music Decade
  • Artist Name
Coverage Options Property
  • Rented Equipment Limit
  • Props, Sets, Wardrobe Limit
  • Negative Film/Faulty Stock                               Include                     Exclude
  • Extra Expense                                                 Include                     Exclude
  • Third Party Property Damage                             None                         $250,000.
                                                                          $500,000.                  $1,000,000.
General Liability
  • Blanket Additional Insured/Certificates of Insurance                     Automatically Included
    (Except City Certificates)
  • Aggregate/Occurrence Limit
    $1,000,000 / $1,000,000                $2,000,000 / $1,000,000                     $2,000,000 / $2,000,000
  • City Certificates                                                                        Include         Exclude
  • Waiver of Subrogation                                                               Include         Exclude
Umbrella
  • Umbrella Limit                                 None           $1,000,000           $2,000,000           $3,000,000
Hired & Non-Owned Auto
  • Liability $1,000,000                                                                   Include                       Exclude
  • Physical Damage $125,000 per vehicle/ $500,000 aggregate        Include                      Exclude
Workers Compensation
(Available in CA, FL, NC, NY, TX only)
  • Workers comp required by SAG?           Yes             No
  • Number of                     Cast          
                                        Crew          
                                        Volunteers  
  • Payroll                          W-2          
                                        1099          
                                        Deferred     
                                        Other        

  • Payroll Company Name (if any)
  • Officer 1 Name & Title
  • Officer 2 Name & Title