Fill - Free fillable Application - Film School36-9970 PDF form

FILM SCHOOL APPLICATION

SUBMISSION REQUIREMENTS

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Currently valued insurance company loss runs for the current policy period plus three (3) prior years

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Synopsis of available programs

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Acord applications for all lines requested except Inland Marine, General Liability and Hired and Non-Owned Auto

GENERAL INFORMATION

Name of Applicant:

Type of Entity:

LLC

LLP

Corp

Individual

Non-Profit

Other:

Contact Name:

Premise Address: (No PO Boxes)

City:

State:

Zip Code:

Mailing Address: (If different from Premise Address)

City:

State:

Zip Code:

Website: www.

Risk Management Contact:

Risk Management’s Phone:

Risk Management Email:

Description of film school operations:

Requested effective dates of policy:

Will any productions include any hard-core or soft-core pornography?

Yes

9. Will any productions include any stunts, pyrotechnics, aircraft, boats, animals, race tracks, race

courses, helicopters, motorbikes, snowmobiles, ATV’s, blanks, squibs, guns or other hazardous

activities?

Yes

If yes, please provide details on a separate document.

10.

Will any productions take place outside the United States?

Yes

If yes, please explain:

11. Confirm your understanding that student productions are covered only if student is currently

enrolled at the film school and the project is a school sanctioned project.

Yes

12.

Any insurance declined or cancelled in the past 3 years (not applicable in Missouri)?

Yes

If yes, please explain:

SECTION I – PREVIOUS CARRIER INFORMATION

Carrier

Expiration

Annual Premium

General Liability

Inland Marine

Film School Application

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SECTION II – GENERAL LIABILITY

PRODUCTION AND STUDENT DETAILS:

1. School’s Professor(s): (first and last name(s))

2. Year the school was established:

3. Number of students enrolled on an annual basis:

4. Length of academic term (in weeks):

PRODUCTION INFORMATION

1. Estimated annual gross production cost: $

2. Maximum gross production cost on any one project: $

3. Maximum days per production:

4. Number of school sanctioned projects per student:

5. 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 * Use of trains or railroads * Expensive antiques or autos

* Other dangerous auto scenes * Use of aircraft, helicopters or balloons * Underwater filming

* Use of animals * Auto chase scenes * Filming above fifty feet

* Filming near / on water * Use of pyrotechnics * Auto crash scenes

* Underground filming * Other stunts or hazards

A. Description of the scene and storyboard.

B. Details on where and how the scene will be performed.

C. Details on 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 policies. Coverage can only be

cons

idered 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.

SECTION III – ABUSE AND MOLESTATION

1. Does the Applicant’s current insurance program include Abuse and Molestation coverage? N/A Yes No

2. Will children (under age 18) be included in any productions? Yes No

If yes, please provide ages and describe scenes in which they will be participating:

3. Are the child’s parents or legal guardian(s) required to be on-set when filming? Yes No

4. 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

5. Does the Applicant verify employment references for employees and volunteers? Yes No

6. Does the employee handbook have a written crisis plan for dealing with employees, volunteers,

victims, parents, authorities and the media if you have an incident of abuse? (If yes, attach a copy)

Yes No

7. Have any incidents resulted in an allegation of sexual abuse? Yes No

a. If yes, was the case settled? Yes No

b. Was the case taken to trial? Yes No

c. Amount paid for damages to the victim? $

8. Does the Applicant’s state allow criminal background checks? Yes No

If yes, does the Applicant run criminal background checks prior to hire for:

Employees: Yes No Volunteers: Yes No

Film School Application

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SECTION IV – INLAND MARINE

*Schedule required for individual items valued in excess of $25,000

Does the Applicant rent school equipment to students?

Yes

With regard to film coverage – does the Applicant require coverage for damaged film or media?

Yes

Item

Limit of Liability

Deductibles

Owned cameras and camera equipment

(minimum deductible $2,500)

Props, Sets and Wardrobe

Fine Arts, Jewelry, etc.

Extra Expense

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

Office Contents:

Negative / faulty coverage

Film: %

35mm

Film: %

16mm

Film: %

70mm

Video: %

Disc: %

CD-ROM: %

3D: %

Other: %

Will the Applicant be using any specialized computer programs to create any images or effects?

Yes

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 the processing / post laboratory:

Security controls for equipment while on set or location:

Is there a private firm or security employees guarding equipment while on site?

Yes

If yes, are they:

Hired

Employed

If hired, please provide cost and attach certificate of insurance: $

If employed, please provide payroll: $

Is equipment inventory checked at the end of each shooting day?

Yes

SECTION V – HIRED AND NON-OWNED AUTO

Does the Applicant allow employees to use their own personal vehicles for its business?

Yes

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.

Does the Applicant obtain Motor Vehicle Reports?

Yes

If yes, how often?

Does the Applicant confirm that all employees who regularly use their cars for business purposes

carry minimum personal auto limits?

Yes

If yes, what minimum limits are required: $

Please provide the approximate cost of hire for all hired or leased autos during the course of the

policy period: $

Is hired auto physical damage required?

Yes

If yes, what is the maximum value of hired vehicle the Applicant would like insured?

NOTE: Physical Damage deductibles: $100 Comprehensive / $1,000 Collision if coverage is requested.

Film School Application

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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

CTION 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 School Application

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CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL

QUESTIONNAIRE

Name of Applicant:

Address of Applicant:

City: State: Zip:

Website: www:

Nature of Operations:

1. Annual sales or revenue: $

2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)

belonging to customers, clients, or other third parties, other than employees?

If yes, please indicate the types of Personally Identifiable Information held (check all that apply):

Yes No

a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or

other State Identification Numbers

b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)

c. Credit or Debit Card Information

3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for

damage to their computer system(s) arising out of the operation of the Applicant’s computer

system(s)?

Yes No

b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a

lawsuit again

st the Applicant

alleging invasion or interference of rights of privacy or the

inappropriate disclosure of Personally Identifiable Information (PII)?

Yes No

c. During the last three (3) years, has the Applicant been the subject of an investigation or

action by any regulatory or administrative agency for privacy-related violations?

Yes No

d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a

claim being made against them for the coverage being applied for?

Yes No

PI-CYBE-APP (11/16)

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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

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, RI, TN, VA, VT, WA AND WV).