Fillable MEDIA LIABILITY COVER PRO APPLICATION (Philadelphia Insurance Companies)

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MEDIA LIABILITY COVER PRO APPLICATION (Philadelphia Insurance Companies)

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Application – Film Producer and Distributor
Page 1 of 9
MEDIA LIABILITY COVER PRO
SM
APPLICATION
Film and Program Producer
Film, Program, Video and Home Entertainment Distributor
NOTICE: This Media Liability coverage may be provided on an occurrence or claims-made basis.
If coverage is requested for Media Liability exposures, please complete the Media Content Liability Application
If coverage is requested for Network Security, please complete the Cyber Security Liability Application
Whenever used in this Application the term Applicant shall mean the named entity, any subsidiary, any
independent contractor while acting on your behalf, but solely as respects media activities and any individual
insured.
SUBMISSION REQUIREMENTS
Distributor Attachments
• Most recent financial statement or corporate annual report
• List of titles to be distributed
• Sample contract used with producers and exhibitors
Producer Attachments
• Most recent financial statement or corporate annual report
• Resumes of principals identifying other works
• DVD or script of work
• A clearance letter from counsel, if one exists
ACCOUNT INFORMATION
Applicant’s name:
Applicant’s principal location:
Address:
City: State: Zip:
Telephone: E-mail address:
Website: www. Date established:
SECTION I – GENERAL INFORMATION
1. Idenitfy all media activities for which the Applicant is seeking coverage:
Film, Program, Video, Home Entertainment Distribution
Film or Program Production
Other:
2. Is the Applicant controlled, owned, affiliated or associated with any other corporation or
company?
Yes No
If yes, please advise:
3. Please list the name(s) and address(es) of any branch offices, joint ventures, affiliates, subsidiaries or other
related entities. Include a brief description of their operations and indicate if coverage is requested:
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Application – FIlm Producer and Distributor
Page 2 of 9
4. During the past five (5) years, has the name of the Applicant been changed or has(have)
any other media business(es) been acquired, merged into, or consolidated with the
Applicant?
Yes
No
If yes, provide a complete explanation detailing any liabilities assumed.
5. Geographic area(s) of media operations:
Local State Multi-State National International
6. Does the Applicant belong to any professional societies / associations? Yes No
If yes, provide the designation/affiliation:
7. Dates of the Applicant’s current fiscal period: From: To:
PAST FISCAL
YEAR
CURRENT
FISCAL YEAR
ESTIMATE
NEXT YEAR
Total Gross Annual Revenue: $ $ $
Revenue from Media Operations for which coverage is requested: $ $ $
SECTION II – MEDIA OPERATIONS
MARK ALL SECTIONS FOR WHICH COVERAGE IS REQUESTED
FILM, PROGRAM, VIDEO AND HOME ENTERTAINMENT DISTRIBUTOR
1. Has the Applicant produced any of the films being distributed? Yes No
If yes, please advise:
2. Identify the type of films distributed:
3. Are any of the films or programs:
Adult/pornographic Yes No
Foreign Yes No
Reality (unscripted situations with non-actors) Yes No
If yes, please explain:
4. Identify percentage of film produced in foreign countries and identify country: %
5. Will any of the films or other works be distributed outside the U.S.? Yes No
If yes, have all foreign rights been negotiated?
Yes No
6. Are all of the films or works distributed pursuant to a contractual agreement? Yes No
If no, please explain:
7. Does the Applicant own any of the works? Yes No
If yes, please explain:
8. Are all producers contractually required to defend and indemnify the Applicant? Yes No
9. Does the Applicant require producers to maintain errors and omissions insurance and
provide proof of insurance?
Yes
No
If no, please explain:
10. Are contractual agreements utilized with film exhibitors? Yes No
If no, please explain:
11. Does the Applicant exhibit any films or works? Yes No
If yes, please explain:
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Application – Film Producer and DIstributor
Page 3 of 9
FILM AND PROGRAM PRODUCER
1. Title of production (“work”) to be insured:
2. Type of work – check all that apply:
Play Motion Picture (full release) Motion Picture (limited) Film Festival
Live Event Television/Cable Series Television Special DVD/On Demand
Music Video Webisode Animated
Documentary/Industrial/Commercial/Educational Previously Released (Identify):
Other (describe):
3. Geographic distribution of work:
4. If television, cable, or radio production, number of episodes:
5. Is work based upon actual events? Yes No
If yes, please advise if the portrayal is accurate or fictionalized:
6. Production budget: $
7. Producer:
8. Author or writer:
9. Synopsis of work and its genesis or inspiration:
10. Release date of work: Length of work, i.e. hours and minutes:
11. Name of distributor:
Term of “rights period” in distribution agreement:
Date of distribution agreement:
12. Has the “chain of title” for work been cleared as to any ownership issues? Yes No
13. Has a title report been obtained for the name of work? Yes No
14. Has a copyright report been obtained for the work? Yes No
15. Has the script been cleared? Yes No
16. Have talent releases been procured from all performers and recognizable extras? Yes No
17.
If no to any of the above questions 12 to 16, please explain:
SECTION III – RISK MANAGEMENT PROCEDURES
USE OF LEGAL COUNSEL
1. Does the Applicant retain law firm(s) with expertise in media law and/or intellectual
property to assist with clearance, content review, and other issues?
Yes
No
If yes, Identify firm(s):
CONTENT GATHERING AND CREATION – PRODUCER ONLY
1. Are hidden cameras, microphones, surveillance or other surreptitious methods utilized to
gather content for the work?
Yes
No
If yes to any of the above, describe how risk is minimized:
2. Does the Applicant rely on confidential sources or material in the work? Yes No
If yes, describe editorial procedures for dealing with conficential sources or information:
3. Did the Applicant commission or create any original music for the work? Yes No
If yes, how is risk minimized
:
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Application – Film Producer and Distributor
Page 4 of 9
4. Are independent contractors retained to create content for the work? Yes No
If yes, are contracts utilized?
Yes No
If yes, are independent contractors required to maintain errors and omissions
insurance?
Yes
No
LICENSING AND USE OF THIRD PARTY CONTENT – PRODUCER ONLY
1. Is any unoriginal music used in the work? Yes No
If yes, have all rights been cleared:
Mechanical Rights: Yes No
Master Rights: Yes No
Synchronization Rights: Yes No
Blanket music performance licenses through music licensing societies, such as ASCAP: Yes No
If no, will all rights be cleared prior to public display of the work?
Yes No
2. Does the work include any unoriginal content, including photographs, film clips, stock
footage, graphics, animation, etc., in the work?
Yes
No
If yes, are all licenses procured?
Yes No
If no, will all rights be cleared prior to public display of the work?
Yes No
3. Have all clearances been obtained for distinctive locations, props, products and artwork? Yes No
If no, will all rights be cleared prior to public display of the work?
Yes No
4. Does the Applicant have a procedure for dealing with unsolicited idea submissions from
third parties?
Yes
No
5. Does the Applicant rely on “fair use” with respect to the use of unoriginal content in the
work(s)?
Yes
No
If yes, please explain:
OTHER CONTENT ISSUES AND RISK MITIGATION – PRODUCER ONLY
1. Are staff members with responsibility for content trained with respect to defamation,
invasion of privacy, intellectual property and other exposures?
Yes
No
2. Is the name, likeness, or portrayal of any living person used in the work(s)? Yes No
If yes, are all clearances obtained?
Yes No
If no, please explain:
3. Is the name, likeness, or portrayal of any deceased person used in the work(s)? Yes No
If yes, have clearances been obtained from heirs or other owners of such rights?
Yes No
If no, please explain:
WEBSITE AND SOCIAL MEDIA ISSUES
1. Are websites used to promote productions or distribution? Yes No
If
yes, please explain:
2. Is any user-generated content uploaded to your website(s)? Yes No
If yes, please answer the following:
a. Is the Applicant in compliance with Section 230 of the Communications Decency Act
with respect to the handling of third party offending content?
Yes
No
b. Is the Applicant in compliance with the Digital Millennium Copyright Act with respect
to notice procedures and the removal of infringing content?
Yes
No
c. Is the Applicant able to remove offending or infringing content in a timely manner? Yes No
d. Are procedures in place for dealing with users who repeatedly post offending or
infringing content?
Yes
No
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Application – Film Producer and Distributor
Page 5 of 9
3. Does the Applicant utilize social media, such as Twitter, Facebook, or Linked-in? Yes No
If yes, please explain:
a. Who posts content on behalf of the Applicant:
b. Are posts edited or otherwise reviewed prior to posting? Yes No
c. Does the Applicant have written social networking guidelines for employees? Yes No
d. Are employees encouraged to utilize their own social media accounts in the course
and scope of their employment?
Yes
No
If yes, please explain:
ANCILLARY PROFESSIONAL SERVICES PERFORMED FOR THIRD PARTIES
1. Does the Applicant provide any professional services related to media operations for a fee,
i.e. post-production services?
Yes
No
2. Describe how the Applicant minimizes/reduces exposure relating to professional services:
MERCHANDISING
1. Does the Applicant engage in any merchandising activities with respect to the work or works? Yes No
If yes, please describe:
2. Have all licenses, including trademarks, been cleared with respect to the merchandise? Yes No
3. What annual revenues are anticipated from merchandising activities: $
SECTION IV – INSURANCE HISTORY AND CLAIMS EXPERIENCE
1. Has any policy or application for similar insurance on your behalf or on behalf of any
predecessor(s) in business ever been declined, canceled, or renewal refused?
(Not applicable in Missouri)
Yes
No
If yes, provide details:
2. Does the Applicant currently carry Commercial General Liability insurance? Yes No
3. Please provide the following information on your Media Liability (E&O) insurance for the past three (3) years:
Name of Insurer: Limits of Liability:$ Deductible:$
Premium:$ Policy period: Occurrence Claims Made
Name of Insurer: Limits of Liability:$ Deductible:$
Premium:$ Policy period: Occurrence Claims Made
Name of Insurer: Limits of Liability$: Deductible:$
Premium:$ Policy period: Occurrence Claims Made
4. Retroactive Date, if one, on current policy:
5. Have any claims or suits been made against the Applicant or the Applicant’s subsidiaries,
predecessor in business, principals or employees in the past five (5) years?
Yes
No
If yes, complete a Claim Supplement form for each incident.
6. Is the Applicant aware of any act, error, omission or any other circumstance that is or could
be a basis for a claim under the proposed insurance?
Yes
No
If yes, complete a Claim Supplement form for each incident.
With regard to questions 5 and 6, it is understood and agreed that if any such claim, act, error, omission,
dispute or circumstance exists, then such claim and/or claims arising from such act, error, omission,
dispute or circumstance is excluded from any coverage that may be provided under this proposed
insurance, and further, failure to disclose such claim, act, error, omission, dispute or circumstance may
result in the proposed insurance being void and/or subject to rescission.
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Application – Film Producer and Distributor
Page 6 of 9
SECTION V – COVERAGE REQUESTED
1. Have any third parties requested coverage as “Additional Insureds” for exposure arising
from your content?
Yes
No
If yes, please advise.
2. Media Liability Coverage requested: Claims Made Policy Retroactive Date:
Occurrence Policy Prior Acts Date:
LIMITS OF LIABILITY
$250,000 $1,000,000 $4,000,000 $7,000,000 $10,000,000
$300,000 $2,000,000 $5,000,000 $8,000,000
$500,000 $3,000,000 $6,000,000 $9,000,000
DEDUCTIBLE: $
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Application – FIlm Producer and Distributor
Page 7 of 9
FRAUD NOTICE STATEMENTS
NOTICE TO 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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL
PENALTIES.”
RESIDENTS OF ALASKA APPLICANTS: “A PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE AN
INSURANCE COMPANY FILES A CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE PROSECUTED
UNDER STATE LAW.”
RESIDENTS OF ARKANSAS 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.”
RESIDENTS OF ARIZONA APPLICANTS: "FOR YOUR PROTECTION ARIZONA LAW REQUIRES THE FOLLOWING STATEMENT TO
APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS
IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES."
RESIDENTS OF 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 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.”
RESIDENTS OF DISTRICT OF COLUMBIA APPLICANTS: “WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING
INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES
INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION
MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.”
RESIDENTS OF FLORIDA RESIDENTS 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 OF THE THIRD DEGREE.”
RESIDENTS OF KANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON 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, OR A CLAIM
FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY 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, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A
CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”
RESIDENTS OF 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.”
RESIDENTS OF LOUISIANA 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.”
RESIDENTS OF MAINE 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 A DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF MARYLAND APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT
IN PRISON.”
RESIDENTS O
F MINNESOTA APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR
DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF 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.”
RESIDENTS OF NEW MEXICO 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 CIVIL FINES AND CRIMINAL PENALTIES.”
RESIDENTS OF 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.”
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Page 8 of 9
RESIDENTS OF OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING
A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT
IS GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF OKLAHOMA APPLICANTS: “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.”
RESIDENTS OF OREGON APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER
TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS
TO ANY MATERIAL FACT, MAY BE VIOLATING STATE LAW.”
RESIDENTS OF 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.”
RESIDENTS OF TENNESSEE 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 INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF TEXAS APPLICANTS: IF A LIFE, HEALTH AND ACCIDENT INSURER PROVIDES A CLAIM FORM FOR A PERSON TO
USE TO MAKE A CLAIM, THAT FORM MUST CONTAIN THE FOLLOWING STATEMENT OR A SUBSTANTIALLY SIMILAR STATEMENT:
"ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON."
RESIDENTS OF VERMONT APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICTION
FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.”
RESIDENTS OF VIRGINIA 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 AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WASHINGTON APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF 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."
Name (Please Print/Type) Title
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR
OFFICER
)
____________________________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the
Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
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Application – Film Producer and Distributor
Page 9 of 9
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
Signature Date
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MEDIA LIABILITY COVER PRO APPLICATION (Philadelphia Insurance Companies)

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