MALP 0009 07 13 Page 1 of 3
ENTERTAINMENT SUPPLEMENTAL APPLICATION
NOTE: For purposes of this Supplemental Application, the term "Entertainment" includes any past or present client,
project, matter, or transaction that involves any of the following: movies or the motion picture industry; television; radio;
theater; performing arts; music industry; musicians or musical performers; journalism; publishing; professional, amateur, or
Olympic sports athletes or coaches; or any kind of celebrity or person who is known to the general public.
APPLICANT’S INSTRUCTIONS:
This form is to be completed if Applicant showed any activity for the Entertainment practice area in Section II., "Applicant's
Practice," on the main application. If space is insufficient to answer any question fully, attach a separate sheet. Answer all
questions completely.
APPLICANT:
1.
a.
Approximately how many different “Entertainment” clients do you currently have?
b.
Which “Entertainment” industries are those clients predominately in?
2.
Please give a brief general overview of the legal services you have provided during the past two (2) years to your
“Entertainment” clients:
3.
Please list the names of any "Entertainment" clients who you have represented or provided legal services to at any
time during the past two years, whose names would be known to the general public. If none, please state "None."
4. During the past two (2) years, have you ever done any of the following for any past or present "Entertainment" client,
project, matter, or transaction? Please check either "Yes or No" for each question. If "Yes" to any part of Question 4.
below, please attach complete details on a separate sheet.
a. Represented or provided any legal service or advice to more than one party or client, relative
to the same basic "Entertainment" matter or transaction?
b. Acted as an intermediary for the purpose of introducing, or of facilitating business or contract
negotiations between two or more different clients of yours?
c. Been directly or indirectly involved financially in any business, investment, or project financing
matter with any of the your "Entertainment" clients?
d. Made, or recommended that your client make, any particular financial or business investment?
e. Rendered any kind of tax advice?
f.
Had custody or control at any time of any funds belonging to one of your "Entertainment"
clients?
g. Been involved in making, or arranging for, the capitalizing or financing of the production or
distribution of any motion picture or other "Entertainment" project or venture?
h. Acted as a sports agent for, or negotiated any kind of contract on behalf of, any professional,
amateur or olympic sports athlete or coach?
i.
Negotiated any terms of any personal appearance, merchandising, publishing, licensing,
royalty, or franchising agreement on behalf of any "Entertainment" client?
j. Rendered any advice or opinion relative to clearance of rights issues or licensing matters?
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
MALP 0009 07 13 Page 2 of 3
5. During the past two (2) years, has the Applicant, or anyone associated with the Applicant at any time, done either of
the following:
a. Represented in any way, or provided any kind of legal service or advice, or any other service
or advice, to any kind of past or present "Entertainment" client, project, or venture that has
gone insolvent, gone into liquidation, trusteeship or receivership, or has gone into any kind of
voluntary or involuntary bankruptcy proceeding?
b. Been named as a defendant in any kind of civil litigation which is in any way related to any
past or present "Entertainment" client or project, or venture?
If "Yes" to any part of Question 5. above, please attach complete details on a separate sheet.
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same representations and conditions.
Notice to Florida Applicants: 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 the
third degree.
Notice to New York Applicants: 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 also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
Signature of Owner, Officer or Partner Print or Type Name and Title Date (month-day-year)
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
Notice to Alabama Applicants; Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution, fines, or confinement in prison, or any combination thereof.
Notice to Arkansas, District Of Columbia, New Mexico, Rhode Island And West Virginia Applicants: Any person who
knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in
an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Notice to Colorado Applicants: 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 claiming with regard to a settlement or award payable for insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Notice to Kansas Applicants: It is unlawful to commit a “fraudulent insurance act” which means 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 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, any information concerning any fact material thereto.
Notice to Kentucky Applicants: 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.
Notice to Maine, Tennessee, Virginia and Washington Applicants: 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 denial of insurance benefits.
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Notice to Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
Notice to Ohio Applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Notice to Oklahoma Applicants: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Notice to Pennsylvania Applicants: 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.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance may be
guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other states: 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 the person to criminal and civil penalties.