Fill - Free fillable Music Professional Liability Application (Access E&S Insurance Services) PDF form

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Overland Park, Kansas 66211

913.384.4800 t

913.384.4822 f

onebeaconpro.com

Music Professional Liability Application

Recording Companies

Music Publishing Companies

Musical Artists: Arrangers ● Composers ● Lyricists● Musicians ● Musical Producers

Performing Artists and Groups

NOTE: Unless the policy form provides coverage for Defense Costs In Addition to the Limits of Liability, the Limits

of Liability shall be reduced by defense costs. Please read the entire policy carefully. Execution of this Application

does not bind the Company to issue a policy. All questions must be answered completely. All requested

attachments must be included.

SECTION I – Music Activities

: Complete Applicable Section(s) - Recording Company (Section A), Music

Publishing Company (Section B) or Musical Artist (Section C). All Applicants

must then complete SECTIONS II and III.

A. Music Recording Company

Please submit the following information with your Application. Attach Additional Sheet If Necessary

Catalog of signed recording artists/groups and compositions and recordings;

Specimen copy of contract used with recording artists/groups;

 Applicant’s marketing materials regarding Applicant’s recordings; and

 Current loss run of open and closed claims involving the Applicant and/or any of its musical artists/groups

during the past five (5) years.

1. Applicant Information — Identified as the Named Insured.

Name of Applicant:

Street Address

City

State/Province

Zip/Postal Code

Telephone

Fax Web Address

Year Established

Corporation Partnership Individual Joint Venture

All subsidiaries (ownership greater than 50%) applying for coverage under this Policy__

________

_______________________________________________________________________________________

_

®

A Division of OneBeacon Professional Partners

Music Liability Application – Musical Artist (ed. 11/07) DOC

2

Websites over which the Applicant’s recordings are disseminated___ ______________________

_______________________________________________________________________________________

_

Names of musical artists/groups for whom music is recorded and

distributed______

____________

_______________________________________________________________________________________

_

_______________________________________________________________________________________

_

Musical Artists’/ Groups’ Label History for past 10

years___

_______________________________

________________________________________________________________________________________

2. Gross Annual Revenues from distribution activities: United States: $

Canada: $

International: $

Identify any international distribution network by country, outside the United States and Canada.

Percentage of revenues derived from:

% Sound Recordings (includes distribution)

% Musical Performances

% Videos

% Other (Describe)

_

____________________________

_

3. Coverage Terms Sought Under This Policy

(Note: The Retention applies to loss and defense costs)

Limits of Liability $

Retention $

Is coverage needed for music videos embodying Applicant’s rec

ordings? Yes No

4. Is Applicant a member of any music associations? If so, please identify:

_____________________________

_______________________________________________________________________________________

_

Is Applicant a member of, or represented by:

ASCAP BMI SESAC Other

5. Number of:

Master Recordings in catalog

Master Recordings produced and released annually

Mechanical & Synchronization licenses utilized annually

3

6. Please identify percentages of recordings, and revenues derived therefrom, in Applicant’s catalog :

% $ Children’s Songs % _ _$ Pop

% _$ Classical Music % _ _$ Rap/Hip Hop

% _$ Country % _ _$ Religious Music/Gospel

%_ _$ Folk % _ _$ Rhythm & Blues

%_ _$ Hard Rock % _ _$ Rock

% _$ Jazz % _ _$ Serious (Operas, Chorales, etc.)

% _ _ $ Other ___________________

7. Percentage of recordings or arrangements that are:

% Original % Licensed from third parties

8. Applicant’s top revenue generating recordings and dates of release:

______________________

9. Loss Prevention and Management

Music Counsel

Name of counsel

Telephone

Name of firm

Address

City

State/Province Zip/Postal Code

Telephone

Fax E-Mail

Does counsel clear intellectual property materials involving music?

Yes No

Is counsel on retainer?

Yes No

Describe clearance procedures and routines for identifying and resolving any copyright issues or attach a

copy of written procedures.

Business Counsel

Name of counsel

Telephone

Name of firm

Address

City

State/Province Zip/Postal Code

Telephone

Fax E-Mail

10. Clearance Procedures and Operations

Does Applicant’s musical artists/ groups sample other music?

Yes No

If “yes,” what are the policies and procedures utilized in connection with sampling: _

___________

4

_______________________________________________________________________________________

_

Does Applicant maintain written contracts or agreements with persons providing

content or services for any of Applicant’s recordings, other than contracts or

agreements with musical groups?

Yes No

If “yes,” provide a specimen copy of the contract wording)

Does Applicant require any person providing original content or services to:

a. indemnify Applicant for claims arising out of such materials or services

provided?

Yes No

b. provide proof of liability insurance for songwriting, composition or promotional

activities?

Yes No

Does Applicant have Comprehensive General Liability Insurance for bodily injury

and property damage relating to performances and touring?

Yes No

B. Music Publishing Company

Please submit the following information with your Application. Attach Additional Sheet If Necessary.

Catalog of compositions;

Sample agreements with musical artists; and

Current loss run of open and closed claims involving the Applicant during the past five (5) years.

1. Applicant Information — Identified as the Named Insured.

Name of Applicant:

Street Address

City

State/Province Zip/Postal Code

Telephone

Fax Web Address

Year Established

Corporation Partnership Individual Joint Venture

All subsidiaries (ownership greater than 50%) applying for coverage under this

Policy__

_________

_______________________________________________________________________________________

_

Websites over which the Applicant’s musical works are

marketed_______

___________________

_______________________________________________________________________________________

_

2. Gross Annual Revenues from licensing: United States: $

Canada: $

5

International: $

Identify any international licensing network by country, outside the United States and Canada.

Percentage of revenues derived from:

% Other Music Publishing Activities (Describe) __________________

_______________________________________________________________________________________

_

3. Coverage Terms Sought Under This Policy

(Note: The Retention applies to loss and defense costs)

Limits of Liability $

Retention $

4. Is Applicant a member of any music associations? If so, please identify: __

_________________

_______________________________________________________________________________________

_

Is Applicant a member of, or represented by:

ASCAP BMI SESAC Other

5. Number of:

Musical works in catalog

Mechanical & Synchronization licenses granted annually

6. Please identify percentages of musical works and revenues derived therefrom, in Applicant’s catalog :

% _ _ $ Children’s Songs % _ _$ Pop

%_ __ $ Classical Music % _ _$ Rap/Hip Hop

%_ __ $ Country % _ _$ Religious Music/Gospel

%_ __ $ Folk % _ _$ Rhythm & Blues

%_ __ $ Hard Rock % _ _$ Rock

%_ _ $ Jazz % _ _$ Serious (Operas, Chorales, etc.)

% _ __$ Other ___________________

7. Applicant’s top revenue generating compositions and dates of release:

_________________________

__________________________

8. Loss Prevention and Management

Music Counsel

Name of counsel

Telephone

6

Name of firm Address

City

State/Province Zip/Postal Code

Telephone

Fax E-Mail

Does counsel clear intellectual property matters involving musical works?

Yes No

Is counsel on retainer?

Yes No

Describe clearance procedures and routines for identifying and resolving any copyright issues or attach a

copy of written procedures.

Business Counsel

Name of counsel

Telephone

Name of firm

Address

City

State/Province Zip/Postal Code

Telephone

Fax E-Mail

9. Clearance Procedures and Operations

Does Applicant maintain written contracts or agreements with musical artists (song writers, composers,

arrangers, lyricists) from whom they license musical works?

Yes No

a. Does Applicant require the musical artist to represent and warrant that the

musical work is original?

b. Does the agreement between the Applicant and the musical artist require the

songwriter to defend and indemnify the Applicant for claims arising from the

musical work?

Yes No

c. Does the agreement require the musical artist to provide proof of liability

insurance for songwriting, composition or promotional activities?

Yes No

C. Musical Artist

Please submit the following information with your Application. Attach Additional Sheet if Necessary.

Catalog of compositions/recordings;

Specimen copy of contract used with distributors;

 Applicant’s marketing materials regarding Applicant’s musical work(s); and

 A current loss run for open and closed music liability claims during the past five (5) years.

1. Applicant Information — Identified as the Named Insured.

Name of Applicant:

Street Address

City

State/Province Zip/Postal Code

Telephone

Fax Web Address

Year Established

7

Corporation Partnership Individual Joint Venture

Artist’s/Band’s Name(s)____

_______________________________________________________

_______________________________________________________________________________________

_

Recording Label History for past 10 years__

___________________________________________

Websites over which the Applicant’s works are distributed__

___

______________________________

_______________________________________________________________________________________

_

2. Name and title of all band members:___

_____________________________________________

_

_______________________________________________________________________________________

_

_______________________________________________________________________________________

_

3. Identify any former band members: ___________________________________________________________

4. Gross Annual Revenues from music activities: United States: $

Canada: $

International: $

Identify international music activities, by country, outside the United States and Canada.

5. Percentage of revenues derived from:

% Music Writing % Sound Recordings (includes distribution)

% Music Performing % Videos

% Other (Describe) ____________________________________________

6. Coverage Terms Sought Under This Policy

(Note: The Retention applies to loss and defense costs)

Limits of Liability $

Retention $

Applicant’s work(s) to be covered under this Policy, including videos embodying the work and website(s)

devoted to the work(s)___

_________________________________________________________

Is merchandising coverage needed for the Applicant’s work set forth above Yes No

7. Is Applicant a member of any music associations or unions? If so, please identify: _________________

___________________________________________________________________________________

_

Is Applicant a member of, or represented by:

8

ASCAP BMI SESAC Other

8. Does Applicant license mechanical rights?

Yes No

If “yes,” through Harry Fox

Yes No Directly Yes No Others Yes No

If “others,” please identify: ______

_______________________________________________

9. Number of:

Compositions in catalog

Master Recordings in catalog

Master Recordings produced and released annually

Compositions published in sheet or folio form annually

Mechanical & Synchronization licenses granted annually

10. Percentages of recordings in Applicant’s catalog:

% Children’s Songs % Pop

% Classical Music % Religious Music

% Country % Rhythm & Blues

% Folk % Rock

% Hard Rock % Serious (Operas, Chorales, etc.)

% Jazz % Other

11. Percentage of recordings or arrangements that are:

% Original % Licensed from third parties

12. Applicant’s top revenue generating works and dates of release:

_________________________

__________________________

13. Loss Prevention and Management

Music Counsel

Name of counsel

Telephone

Name of firm

Address

City

State/Province Zip/Postal Code

Telephone

Fax E-Mail

Does counsel clear intellectual property materials involving music?

Yes No

Is counsel on retainer?

Yes No

Describe clearance procedures and routines for identifying and resolving any copyright issues or attach a

copy of written procedures.

Business Counsel

9

Name of counsel Telephone

Name of firm

Address

City

State/Province Zip/Postal Code

Telephone

Fax E-Mail

Applicant’s Manager

Name of counsel

Telephone

Name of firm

Address

City

State/Province Zip/Postal Code

Telephone

Fax E-Mail

Number of years as Applicant’s manager: _________________

14. Clearance Procedures and Operations

Is a Musicologist used?

Yes No

If “yes,” please identify “who” and describe the Applicant’s policy and practice regarding such use:

_______________________________________________________________________________________

_

Does Applicant sample other music?

Yes No

If “yes,” what are the policies and procedures utilized in connection with sampling: _

_______________

_______________________________________________________________________________________

_

Does Applicant maintain written contracts or agreements with persons providing

original music, lyrics, etc.?

Yes No

(If ”yes,” provide a specimen copy of the contract wording)

Does Applicant require persons providing original materials or services to:

a. Indemnify Applicant for claims arising out of such materials or services

provided?

Yes No

b. provide proof of liability insurance for songwriting, composition or

promotional activities?

Yes No

Does Applicant have Comprehensive General Liability Insurance for bodily injury

and property damage relating to performances and touring?

Yes No

SECTION II - Insurance and Claim Information:

To Be Completed by all Applicants.

1. Has the Applicant commenced suit, been sued or threatened with litigation in

the past 10 (ten) years?

Yes No

10

If “yes,” please advise generally. In respect to claims arising from music activities, please include the

amount of defense costs incurred, any applicable retention spent, and the amount of any judgments or

settlements paid. If the claim has not yet been resolved, please provide the amounts for which the claim

has been reserved.

2. Does the Applicant know of any situation that could give rise to a claim?

Yes No

If “yes,” please attach complete details and advise whether the claim has been reported.

3. Has the Applicant been refused similar insurance in the past five years?

Yes No

If “yes,” please advise __

__________________________________________________________

____________________________________________________________________________________

4. (In the State of Missouri, the following question does not apply.)

Have any media liability insurers ever canceled or non-renewed coverage?

Yes No

If “yes,” please advise

5. Has the Applicant had music liability insurance in the past three years?

Yes No

If “yes,” please identify the following or attach Declarations:

Insurer

Policy Limits Retention Policy Term Premium

1.

2.

3.

Fraud Warning

Any person who knowingly and with intent to defraud any insurance company or another person files an

application of 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 and subjects the person to criminal and (NY: substantial) civil penalties. In Maine and Virginia,

insurance benefits may also be denied.

SECTION III - REPRESENTATIONS:

To Be Completed by all Applicants.

By signing this Application, the Applicant agrees:

 The statements and answers contained herein and in any attachments are complete and accurate;

 The statements and answers are complete and accurate representations on behalf of all persons and

entities for whom coverage is being sought;

 That the Company relies upon such representations as a condition to providing insurance; and

 If there is a material change in respect to the statements and answers in this Application before the

inception date of the policy, the Applicant must immediately notify the Company. Any outstanding offer

to provide insurance may be modified or withdrawn by the Company.

The statements and answers made in this Application for insurance and in any attachments are true and correct

to the best of my knowledge.

Applicant Title

(Director, Partner or Principal)

11

Signature Date

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