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MEDIA/PUBLISHING SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Core Product Media/Publishing Supp V.01/2011 Page 1 of 2
MEDIA/PUBLISHING SUPPLEMENTAL APPLICATION
Named Insured
Name of organization
(If different)_________________________________________________________________
1. Does your organization use a logo in any of your materials? Yes No
If yes, has the logo been copyright searched?
Yes No
By whom:_________________________________________________________________
Is your logo copyrighted or registered? Yes No
2. Are all media publications(including internet, commercials, and written materials)
subject to legal review prior to use? Yes No
3. Do you always obtain waivers that specifically release your organization from all
Is Liability arising from personal or advertising injury, prior to using the likeness
of others or prior to using the work product of others? Yes No
4. Does your organization:
a) Publish written or recorded materials?
Yes No
If yes, complete section A
b) Have a website, host an internet chat room or message board? Yes No
If yes, complete section B
c) Produce commercials, television show or radio show? Yes No
If yes, complete section C
A. PUBLISHED MATERIALS:
5. Do you publish pamphlets, brochures or newsletters?
Yes No
If yes, attach samples of each.
6. Do you publish recorded materials or books? Yes No
If yes, attach a catalog of materials.
7. Materials are designed by: employee volunteer contractor
If materials are designed by a contractor, is a certificate of insurance obtained,
that includes coverage for personal and advertising injury? Yes No
8. What are the annual sales from materials produced or created by you?_________________
9. Does your organization carry a publisher’s liability policy?
Yes No
B. WEBSITE/INTERNET:
10. Site is designed by:
employee volunteer contractor
If materials are designed by a contractor, is a certificate of insurance obtained,
that includes coverage for personal and advertising injury? Yes No
11. Does your website contain links to other websites
Yes No
If yes, who reviews the content of the linked websites?______________________________
12. Does your webmaster preserve historical “views” of your website?
Yes No
How often does this occur?______________________________
13. Do you sell any good or services from the internet? Yes No
Is the transmission of private information secure?
Yes No
What are the annual gross sales from the internet?______________________________
14. Does your organization sponsor a “chat room” or message board? Yes No
If yes, does your organization have procedures in place to monitor or edit messages?
Yes No
If yes, attach a description of procedures.
Core Product Media/Publishing Supp V.01/2011 Page 2 of 2
C. RADIO OR TELEVISION:
Yes No
15. How many commercials or public service announcements(PSA’s) are produced either by you or
on your behalf annually?____________________________________________________
What are the topics of each? Attach a separate sheet.
16. Commercials are produced by:
employee volunteer contractor
If commercials are designed by a contractor, is a certificate of insurance obtained,
that includes coverage for personal and advertising injury? Yes No
17. Does your organization sponsor or produce a radio or television program(s)?
Yes No
If yes, attach a program schedule and description of program.
18. Does your organization carry a publisher’s liability policy?
Yes No
The undersigned represents that all statements and answers to questions are true, complete and accurate and that there has
been no suppression or misstatement of fact.
THE APPLICANT ACCEPTS NOTICE THAT HE/SHE IS REQUIRED TO PROVIDE WRITTEN NOTIFICATIONS TO THE
COMPANY OF ANY CHANGES IN THE RESPONSES GIVEN TO THIS APPLICATION THAT MAY HAPPEN BETWEEN
THE SIGNATURE DATE BELOW AND ANY PROPOSED EFFECTIVE DATE.
The undersigned is an authorized representative of the applicant and certifies that reasonable enquiry has been made to
obtain the answers to questions on this application. He/She certifies that the answers are true, correct and complete to the
best of his/her knowledge.
Date Signed Signature of Applicant
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MEDIAPUBLISHING SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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