Fillable COVER-PRO APPLICATION PUBLISHER SUPPLEMENT 2. Please state the (Philadelphia Insurance Companies)

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COVER-PRO APPLICATION PUBLISHER SUPPLEMENT 2. Please state the (Philadelphia Insurance Companies)

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COVER-PRO
SM
APPLICATION
PUBLISHER SUPPLEMENT
1. Full name of the Applicant Firm:
2. Please state the percentage of the total gross annual revenu
e derived from each of the following:
Broadcasting / Telecasting: % Magazine publishing: %
Cablecasting: % Book publishing: %
Newspaper publishing: %
Internet / Website:
%
Other:(specify). % TOTAL MUST EQUAL 100 %
3. If the Applicant is e
ngaged in book publishing, please complete the following: If none, che
ck here
3a. Gros
s annual income last fiscal year:
Publishing: $ Distribution: $
Subsidi
ary Rights: $
3b. Please specify the number of:
Original titles: Reprints: Titles distributed for others:
3c. Please indicate the percentage of the types of books published:
Textbooks: % History / Biography: %
How to / Instructional: % Fiction: %
Current biography / Autobiography: % Poetry: %
Social political commentary: % Children’s: %
Investigative reporting / exposures: % Celebrity: %
Technical: % TOTAL MUS
T EQUAL
100 %
Religious: %
Classics: %
3d. Are publications reviewed for controversial material and originality by:
In house counsel: Both:
Outside counsel: Other:(specify)
4. If the Applicant is involved in newspaper publishing
, please complete the following: If none, check here.
4a. Please list all publications: Frequenc
y of A
verage
Name of Publication Location Circulation Circulation
4b. Primary circulation areas are:
National: Regional: Campus: Metro:
Internet / Website:
Rural:
Suburban: Community: Other:(specify)
4c. Does the Applicant engage in investigative reporting or exposes? Yes No
If yes, provide full details including procedures for documenting sources of information.
PI-PLSP-PUSUPP 08/
10 Page 1 of 3
Print Application
Clear Application
PI-PLSP-PUSUPP 08/10 Page 2 of 3
4d. Are written hold ha
rmless agreements executed with advertisers and advertising age
ncies? Yes No
4e. Are letters to the editor edited? Yes No
4f. Is a law firm consulted with respect to media law? Yes No
If yes, please provide the name, address and number of years experience in media law?
5. If the Applicant is engaged in magazine publishing
, please complete the following: If none, check here.
5a. Please list all publications:
Frequenc
y of
Average
Name of Publication Location
Circulation Circulation
To enter more information, please use the separate page attached to this application
5b. Primary circulation areas are:
National: Regional: Metro: Professional: International: Internet / Website:
5c. Does the Applicant engage in investigative reporting or exposes? Yes
No
If yes, provide full details including procedures for documenting sources of information.
5d. Are written hold harmle
ss agreements executed with advertise
rs and advertising age
ncies? Yes No
5e. Are letters to the editor edited? Yes No
5f. Are written releases obtained from persons appearing in photographs or from photo agencies? Yes No
5g. Do free-lance writers provide written warranties with respe
ct to originality of content, libelou
s matter, and
authenticity of sources? Yes No
5h. Is a disclaimer issued with respect to technical information or advice?
Yes No
5i. Is a law firm consulted in respect to media law? Yes No
If yes, please provide the name, address and number of years experience in media law.
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companie
s Cover-Pro
sm
application and is subject to the same conditions as stated on the application.
Name (Please Print) Title (Mus
t be Principal, Partner or O
fficer)
__________________________________________
Signature Date
Print Application
Clear Application
PI-PLSP-PUSUPP 08/10 Page 3 of 3
A
DDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identif
y
the question number to which you are referring.
__________________________________________
Signature Date
Print Application
Clear Application
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COVER-PRO APPLICATION PUBLISHER SUPPLEMENT 2. Please state the (Philadelphia Insurance Companies)

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Completed 7 November 2020

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