Miscellaneous - Billing Inquiry

Contact Information:

Name of Company/Organization:

Entity Type:

Street Address:

City:

State & Zip:

Contact Person:

Phone:

Fax:

Email:

Federal ID/Social Security #

Qualification Questions

Any: Stunts, Pyrotechnics, 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

Type of Production

Title of Production

Budget (Gross Production Cost)

Brief Description/Synopsis of Shoot

Cities & States of Shooting Locations

Coverage Dates of the Production

For Music Videos Only

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 Insureds/Certificates of Insurance (except city certificates)

Automatically Included

Aggregate/Occurrence Limit

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, 00 aggregate

Include Exclude

Workers Compensation
(Available in CA, FL, NC, NY, TX only)

Workers comp required by SAG?

Yes No

Number of Cast:

Number of Crew:

Number of Volunteers:

Payroll W-2

Payroll 1099

Payroll Deferred

Payroll Other

Payroll Company Name (if any)

Officer 1 Name and Title

Officer 2 Name and Title

* Insurance coverage cannot be bound or altered by this submission.

Short Term Production Application
Contact Information:
Name of Company/Organization:
Entity Type:
Street Address:
City:
State & Zip:
Contact Person:
Phone:
Fax:
Email:
Federal ID/Social Security #
Qualification Questions
Any: Stunts, Pyrotechnics, 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
Type of Production
Title of Production
Budget (Gross Production Cost)
Brief Description/Synopsis of Shoot
Cities & States of Shooting Locations
Coverage Dates of the Production
For Music Videos Only
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 Insureds/Certificates of Insurance (except city certificates)	Automatically Included
Aggregate/Occurrence Limit
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, 00 aggregate	Include Exclude
Workers Compensation (Available in CA, FL, NC, NY, TX only)
Workers comp required by SAG?	Yes No
Number of Cast:
Number of Crew:
Number of Volunteers:
Payroll W-2
Payroll 1099
Payroll Deferred
Payroll Other
Payroll Company Name (if any)
Officer 1 Name and Title
Officer 2 Name and Title

* Insurance coverage cannot be bound or altered by this submission.