Fillable Application - Film Production36-9969 Application - Fairs and Fairgounds Supplemental Application

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Application - Film Production36-9969 Application - Fairs and Fairgounds Supplemental Application

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FILM PRODUCTION SUPPLEMENTAL APPLICATION
Annual Productions, D.I.C.E. Annual Programs or Film Schools
SUBMISSION REQUIREMENTS
• ACORD applications for all lines requested except Inland Marine, General Liability and Hired/Non-Owned Auto
• Synopsis of each production to be scheduled herein
• Financial statement (Annual term or multiple production policies)
• Currently valued loss runs for the current policy period plus three (3) prior years
SECTION I - GENERAL INFORMATION
1.
Name of Applicant:
2.
Street and Mailing Address:
Premises Address:
Phone Number:
Fax Number:
Website: www.
3.
Applicant is a:
Corporation
Partnership
Other (explain):
4.
Owner’s Name and Title:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
5.
Applicant’s experience in the business:
years
6.
Year business was established:
7.
Type of productions and percentage of activity:
Music Video
%
2
nd
Unit Filming
%
Industrial
Commercials
%
Travel Logs
%
CD Rom
Computer Effects
%
Exercise Videos
%
Animation
Infomercials
%
Still Shots
%
Other:
Other documentaries/infomercials, please describe in detail:
8.
Name three of the Applicant’s major productions or your last three productions:
9.
Number of productions completed in the previous year:
%
%
%
%
Film Production Supplemental Application
Page 1 of 6
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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10. Number of anticipated productions for upcoming 12 months by category (if any):
11.
Does the Applicant distribute any of the items in question 7 above?
Yes
No
If yes, please describe and provide annual receipts:
$
12.
Does the Applicant own or use any drones, UAV’s (unmanned aerial vehicles), or remote
controlled aerial devices?
Yes
No
13.
Has the Applicant had any claims (occurring, not just paid) in the past three (3) years?
Yes
No
If yes, please describe, including date occurring and amounts paid:
14.
Previous insurer and policy number:
15.
Does the Applicant co-produce projects with independent producers?
Yes
No
If yes, please provide a sample copy of co-production agreements. Note: all co-productions require prior
approval from the carrier.
SECTION II - GENERAL LIABILITY
1.
Name and description of production(s) for which coverage is requested:
2.
Start date of production(s):
End date of production(s):
3.
Percentage of location filming:
%
Percentage of studio filming:
%
4.
Gross Production Cost: $
5.
Payroll:
Crew: $
Cast: $
6.
Does the Applicant use independent contractors for your productions?
Yes
No
If yes, does the Applicant require certificates of insurance with limits of $1,000,000 or greater
with the Applicant named as additional insured?
Yes
No
Total cost of independent contractors: $
7.
Has any form of insurance ever been cancelled or declined?
Yes
No
If yes, please explain:
PSA/Public Access Program:
Reality Based TV Show:
SAG Production:
Short Film:
Spec Production:
TV Pilot/ Specials:
TV Series:
Commercial/Promotional/Sales Video:
Editing/Trailer:
Educational/Instructional/Training:
Industrial/Corporate Video:
Infomercial
Miscellaneous Productions:
Photography Shoot:
Pre/Post-Production:
Film Production Supplemental Application
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© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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8.
Stunts, hazards, and special effects:
If the Applicant ever becomes involved in any of the below (*), please notify us immediately and provide
the following (A-D):
* Use of watercraft
* Underwater filming
* Filming near/on water
* Use of trains or railroads
* Use of animals
* Use of pyrotechnics
* Expensive antiques or autos
* Auto chase scenes
* Auto crash scenes
* Other dangerous auto scenes
* Filming above fifty feet
* Underground filming
* Use of aircraft, helicopters or balloons
* Other stunts or hazards
A.
Description of the scene and storyboard.
B.
Details on where and how the scene will be performed.
C.
Details of all safety features put in place to protect people and property.
D.
Name and telephone number of stunt and special effects coordinator.
(Additional information may be requested at a later date.)
NOTE: Use of animals, stunts, dangerous auto scenes, crashes or in air use of aircraft, helicopters, or
balloons are excluded from film productions polic
ies. Coverage can only be considered if operated by
insured independent contractors. Please provide details and certificates of insurance from sub-
contractors with limits not less than $1,000,000 and naming our insured as an Additional insured.
9.
Will children (under age 18) be included in the production?
Yes
No
If yes, please provide ages and describe scenes in which they will be participating:
If yes and Abuse & Molestation coverage is requested, please complete the following:
Are the child’s parents or legal guardian(s) required to be on-set when the child actor is
present?
Yes
No
Does the Applicant’s state allow criminal background checks?
Yes
No
If yes, does the Applicant perform background checks on all persons prior to hiring?
Yes
No
Does the Applicant verify employment references for employees?
Yes
No
Does the Applicant have formal procedures for supervision of employees?
Yes
No
Does the Applicant’s employment process (for employees and volunteers) include verification of
whether the individual has ever been convicted of any crime, including sex-related or child
abuse related offenses, before an offer of employment is made?
Yes
No
Has the Applicant had any incidents resulting in allegation of sexual abuse?
Yes
No
If yes, provide details:
SECTION III - INLAND MARINE
Notes: Schedule required for individual items valued in excess of $25,000.
1.
Film Coverage – does the Applicant require coverage for damaged film or media?
Yes
No
2.
LIMIT OF LIABILITY
DEDUCTIBLES
Owned cameras and camera equipment
(Minimum deductible $2,500)
$
$
Props, sets and wardrobe
$
$
Fine arts, jewelry, etc.
$
$
Extra expense
$
$
Film Production Supplemental Application
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© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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Cont’d
LIMIT OF LIABILITY
DEDUCTIBLES
Third Party Property Damage
$
$
Miscellaneous Equipment (Minimum deductible $1,000)
Rented
$
$
Borrowed
$
$
Electronic Data Processing
Hardware
$
$
Software
$
$
Extra expense
$
$
Negative/Video/Sound/Disc
$
$
Faulty processing
$
$
3.
Negative/faulty coverage
Film: 35mm:
%
Film: 16 mm:
%
Film: 70 mm:
%
Video:
%
Disc:
%
CD-ROM:
%
3D:
%
Other:
%
Will the Applicant be using any specialized computer programs to create any images or effects?
Yes
No
If yes please explain and give the name of the software and provide values:
Name and address of the lab/studio performing the effects:
Name and address of processing/post laboratory:
4.
Security controls for equipment while on set or on location:
Is there a private firm or security employees guarding equipment while on site?
Hired
Employed
If hired, please provide cost and attach certificate of insurance:
$
If employed, please provide payroll: $
5.
Is equipment inventory checked at the end of each shooting day?
Yes
No
6.
Is Worldwide Coverage needed?
Yes
No
(**This coverage is meant for brief filming / photography operations only)
a.
In which countries will filming operations take place?
b.
How long will the shoots be (i.e. two days, one week, etc.)?
c.
How many times will they go to this country in one year?
d.
What productions will they be producing?
SECTION IV - HIRED & NON-OWNED AUTO
1.
Does the Applicant allow employees to use their own personal vehicles for your business?
Yes
No
If yes, how many employees use their own personal vehicle:
If yes, how often:
NOTE: If the Applicant has owned autos, the hired car and non-owned auto coverage should be placed
with the automobile carrier. Explain if an exception is requested.
2.
Does the Applicant obtain Motor Vehicle Reports?
Yes
No
If yes, how often:
Film Production Supplemental Application
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© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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3.
Does the Applicant confirm that all employees who regularly use their cars for business
purposes carry minimum personal auto limits?
Yes
No
If yes, what minimum limits are required: $
4.
Please provide the approximate cost of hire for all hired or leased autos during the course of the
policy period: $
5.
Is hired auto physical damage required?
Yes
No
If yes, what is the maximum value of hired vehicle you would like insured: $
NOTE: Physical Damage deductibles: $100 comprehensive / $1,000 collision if coverage is requested.
Film Production Supplemental Application
Page 5 of 6
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
__________
___________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Film Production Supplemental Application
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© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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Application - Film Production36-9969 Application - Fairs and Fairgounds Supplemental Application

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