COVER-PRO
SM
APPLICATION
ADVERTISING AGENCY/ MEDIA CONSULTANT SUPPLEMENT
1. Full name of the Applicant Firm:
2. Does the Applicant have a review process in place to scree
n material to be used in its advertisi
ng products?
Yes No
If yes, check those categories that the Applicant scre
ens for:
Libel and Slander Trademark Infringement
Copyright Infringement Privacy Infringe
ment
3. Is an attorney review part of the Applicant’s clea
rance
procedures? Yes No
4. Provide a complete description or attach a copy of the Applica
nt’s clearan
ce procedures for
trademarks/copyrights:
(Failure to compl
y w
ill result in denial of copyright/trademark infringement coverage)
5a. Does the Applicant use material created or supplied by third partie
s (e.g. text, videos o
r music) in its advertising
products? Yes No
5b. If yes, does the Applicant obtain prior written clearance from the third party that specifical
ly permits the
Applicant to use such material in its advertising product? Yes No
6. Does the Applicant produce political advertising? Yes No
7. What modes of advertising does the Applicant place? What percent of your annual revenu
e is
derived from
each?
TV: % Radio: %
Telemarketing: % Direct Mail: %
Banner Ads: % E-Mail: %
Public Service Announcements: % Magazines: %
Internet/Website
%
Cable %
Other: (specify):
%
9. Does the Applicant produce “infomercials”? Yes No
The undersigned agrees that as a condition precedent to coverage the Applicant shall have adopted and
adhere
d to wr
itten Clearance Procedures that are reasonably designed to prevent and protect against the
sort of claims for which coverage is provided under this policy.
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companies Cover-Pro
sm
application and is subject to the same conditions as stated on the application.
Name (Please Print) Title (Must be Principal, Partner or O
fficer)
__________________________________________
Signature Date
PI-PLSP-AASUPP 08/10 Page 1 of 2
