Fill - Free fillable Producers E&O Application PDF form

Producer’s E&O Application

About This Program

This application is used to insure a single production or series with a budget

up to of $20,000,000

Required Documents

The following documents are required to apply for coverage:

• This application, including signature on page 10

• Budget top sheet (if cover is for a single production or series)

• Detailed Synopsis (if cover is for a single production or series)

• Title Report (if title coverage and if cover is for a single production or series)

NOTICES:

Applicable in all states but NY: This insurance coverage provides that the policy limit available to pay damages shall be reduced by amounts incurred for

defense costs. Further note that amounts for defense costs shall be applied against the retention amount.

Applicable in NY: This insurance coverage provides that the policy limit available to pay damages shall be reduced by amounts incurred for defense costs,

and may be completely exhausted by such amounts. We shall not be liable for defense costs or for the amount of any judgment or settlement after

exhaustion of the policy limit. Further note that amounts for defense costs shall be applied against the retention amount.

Applicant Information

Named Insured:

Entity Type: Individual LLC LLP Corporation Non-Profit

Applicant Ownership Publicly Traded Privately Held

Country of Residency (if individual):

Country of Registration (all others):

Primary Address (no PO Box):

Mailing Address (if different to primary):

Contact Person:

Phone / Fax:

Email:

Website:

Year Business Established:

Federal ID:

Description of Operations:

Insurance History

Any insurance declined, cancelled or non-renewed that provided the same or similar coverage as the insurance sought? (not

applicable in MO). If yes, provide details:

Yes No

Any prior insurance coverage? If yes, provide details below

Yes No

Policy Type Carrier Policy # Expiration Date Premium

/ /

Are You aware of any claims or legal proceedings made or commenced against You or any of Your officers, members, or

partners within the last five (5) years for: (1) invasion of privacy or false light; (2) IP infringement; (3) defamation; or (4)

breach of contract arising out of the alleged submission of any ideas, story line, or script? If yes, provide details below.

Yes No

Policy/Line Date of Loss Description of Loss Amount of Loss

/ /

Qualification Questions

Does the production involve any of the following: animation, pornographic materials, ride alongs, hidden cameras, pranks

and consumer voting?

Yes No

Will you be using a clearance attorney with at least 5 years of relevant media law experience?

Yes No

Producer’s E&O Application

Clearance, Licenses, Consents, Legal Procedures

Clearance Procedures

1. Have you obtained a title report from a recognized agency? Yes No

2. Is the name or likeness of any actual living person used, portrayed or identifiable in the Named

Production?

If yes, will necessary permissions be obtained prior to first airing, distribution or public

display of the production?

Yes No

3. Is the name or likeness of any actual deceased person used, portrayed or identifiable in the

Named Production?

If yes, will necessary permissions be obtained from personal representatives, heirs or

estates prior to first airing, distribution, or public display of the production?

Yes No

4. Is the production based on an underlying work?

If no:

a) Are you aware of any similar format or concept?

i) If yes, has your attorney confirmed that they are satisfied you can safely proceed

with your exploitation of the work?

b) Has any similar format or similar material been submitted to you at any time?

If yes:

a) Have copyright reports been obtained?

b) Are there any ambiguities, gaps or problems in the chain of title?

c) Has the chain of title of all works on which the production is based been thoroughly

investigated and cleared back to the original copyright owners to determine that all

grants or transfers in the chain of title permit you to assign or sublicense the material

as incorporated in your production?

Yes No

Licenses, Releases, Consents

1. Have you obtained from all writers and other content providers to the production, written

warranties that the content with which they provide you does not infringe the rights of any third

party and have you obtained an indemnity for any breach of this warranty?

Yes No

2. Have you obtained a written agreement from all performers or persons appearing in your

production consenting to their appearance?

Yes No

3. Will any film clips, TV clips or photographs be used in this production?

If yes:

a) Have all licenses and consents been obtained from the copyright owner without

restriction and are you authorized to assign or sublicense the licensed materials as

incorporated in your production?

b) Do you have the authorization of any person or entity depicted in the film clip, TV clip

or photograph to use their depiction in your production and to assign or sublicense

that depiction in your production?

Yes No

4. Have the following musical rights been obtained from the composer and/or performers of

specially commissioned music and/or cleared with the owners of pre-existing music and/or

recordings:

a) Recording and synchronization

b) Performing rights?

c) Right to distribute for all forms of distribution contemplated (home video, etc.)

Yes No

5. Have you or any of your agents been unable to obtain or been refused an agreement or release

after having:

a) Negotiated for any rights in literary, musical or other materials?

b) Negotiated for release from any persons in respect of any material incorporated in the

production?

If Yes, please explain:

Yes No

________________________________

Producer’s E&O Application

Merchandising

1. Is coverage desired for Merchandising for this Production?

If Yes:

a) Have all necessary consents and licenses been obtained in respect of any

associated merchandising?

b) Will appropriate trademarks or other searches be made before merchandising

characters or other matter that might be subject to trademark, unfair competition or

similar claims?

Yes No

Legal Procedures

1. Have you suffered any loss or has any claim, whether successful or not, ever been made

against you that would be covered by this insurance?

If Yes, please attach details including the date of each claim or loss, the amount of the claim

and any remedial action taken.

Yes No

2. Are you aware of any problem which is likely to lead to you suffering a loss or a claim being

made against you that would be covered by this insurance?

If Yes, please attach details of each problem.

Yes No

3. It is understood and agreed that with respect to the above questions if such knowledge of

information exists, any claim or action arising there from is excluded from this proposed

coverage.

Yes No

Producer’s E&O Application

Production Details

Production Information

Title of Production

Type of Production

Commercial Documentary Educational & Training

Feature Film (for theatrical release) Feature Film (not for theatrical release)

Industrial Infomercial Music Video

Radio Series (one episode/week) Radio Series (two or more episodes/week)

Television Mini Series or Docudramas Television Pilot, Special or Feature

Television Series/Daily Programming Television Series/Weekly Programming

Theatrical Stage Production Training Video Video Distributor

Nature of Production

Based on Another Work Controversial Educational

Foreign Language Home & Garden Innocuous

Investigative Reporting Live Programming Talk Show

Reality TV

Type of Work

Entirely fictional and original

Entirely fictional but based on another’s work

Name of Author(s):

Title(s):

Date(s) of Publication:

Entirely fictional but inspired by actual events

Portrayal of actual events with original fictionalization

True portrayal of actual events

Other portrayal. Describe:

Synopsis

Gross Production Cost (Total Budget)

Running time ________ minutes

Initial Release or Air Date

______/______/______

Not previously released or aired

Number of Episodes (if applicable)

Length Per Episodes (if applicable)

Number of Weeks (if applicable)

______________________

Distributor Name & Address

(indicate multiple distributors on an additional page)

_________________________________________________

Distribution Territory

Local 90% of distribution within local area (population less

than 100,000)

Metro 90% of distribution within larger metro area

(population 100,000 or greater)

Regional 90% of distribution within 2 to 6 states

National 90% of distribution within the nation

International Greater than 10% of distribution outside the nation

How will the production be released

(Select all that apply)

Cable/Satellite/Wireless Television

DVD/Videotape Theatrical Release

Internet Theatrical Stage

Radio Other ______________

If DVD/Videotape:

a) Will there be bonus material

Yes No

b) Will bonus materials use same clearance procedures as

Yes No

the rest of the production?

Producer’s E&O Application

Key Personnel

Enter the key personnel. At a minimum, the producer, executive producer and script writer must be listed.

Personnel Role First & Last Name

Executive Producer

Producer

Script Writer

Legal

Attorney’s Name

Firm Name

Firm Address

Phone Number

________________________________

Have you and your attorney read and agreed to exercise due diligence to insure that the

‘Clearance Procedures’ attached are followed?

Yes No

Producer’s E&O Application

Term, Coverages, Additional Insureds

Term

Effective Date

_____/______/______

Coverage Term 1 year 2 years 3 years

Coverage Basis * Claims Made Occurrence

* An occurrence basis may not available in all jurisdictions.

Coverages

Occurrence / Aggregate Limit *

1m/1m 1m/2m 1m/5m 2m/2m 1m/3m 3m/3m

2m/4m 2m/5m 3m/5m 4m/4m 5m/5m

Retention * 10,000 15,000 20,000 25,000 50,000 75,000 100,000

Rights Period Endorsement (Available for occurrence based

policies only)

Include Exclude

Title Coverage (requires title report and carrier approval) Include Exclude

Merchandising Include Exclude

Additional Insured Endorsement Include Exclude

Worldwide Coverage Territory Included

* Indicates a required item

Additional Insureds

Name Address, City, State, Zip Type

Distributor

Broadcaster

Other

Special Wording Requirements:

Rights Period Endorsement Required Yes No

Distributor

Broadcaster

Other

Special Wording Requirements:

Rights Period Endorsement Required Yes No

Distributor

Broadcaster

Other

Special Wording Requirements:

Rights Period Endorsement Required Yes No

Distributor

Broadcaster

Other

Special Wording Requirements:

Rights Period Endorsement Required Yes No

NOTE: Availability of coverage will depend on individual risk characteristics and the State in which insured is located.

Producer’s E&O Application

Legal Notices & State Fraud Disclosures

Additional Documents and Information Incorporated By Reference

All written statements, materials or documents furnished to the insurer in conjunction with this application, regardless of whether such documents are

attached to the policy, are hereby incorporated by reference into this application and made a part hereof, including without limitation any supplemental

applications or questionnaires.

Declaration

I declare that this application form has been completed after proper inquiry and, based on this inquiry, I declare the application contents are true,

accurate, and not misleading.

I declare that I will immediately notify Hiscox, before any contract of insurance is concluded, of any additional information that might render the contents of

this application untrue, inaccurate, or misleading, or if any new fact or matter arises which is material to the consideration of this application for insurance.

I declare that I understand and agree that if any of the contents of this application are intentionally untrue, inaccurate, or misleading, in any material

respect, or if I fail to notify Hiscox of additional information that might render the contents of this application untrue, inaccurate, or misleading, in any

material respect, then Hiscox is entitled to rescind any policy issued pursuant to this application.

I declare that I understand and agree that this application and all materials submitted in connection with this application are incorporated into and form the

basis of any policy issued by Hiscox pursuant to this application.

I declare that by signing this application I am representing that I am duly authorized to execute insurance contracts on behalf of the entity applying for

this coverage and that all representations (whether verbal or written) made in connection with this application are made on behalf of and shall be fully

binding upon such entity.

State Fraud Disclosures:

Notice to Alaska Resident Applicants: A person who knowingly and with the intent to injure, defraud, or deceive an insurance company files a claim

containing false, incomplete, or misleading information is guilty of a felony.

Notice to Arkansas, New Mexico 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 California Resident Applicants: For your protection California law requires the following to appear on this form. Any person who knowingly

presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in prison. Any person who

knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

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 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 authorities.

Notice to Delaware Resident Applicants: Any person who knowingly, and with the intent to injure, defraud or deceive an insurer, files a statement of

claim containing any false, incomplete or misleading information is guilty of a felony.

Notice to 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.

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 Hawaii Resident Applicants: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a

loss or benefit is a crime punish able by fines, imprisonment or both.

Notice to Idaho Resident Applicants: Any person who knowingly, and with the intent to defraud or deceive any false, incomplete or misleading

information is guilty of a felony.

Notice to Indiana Resident Applicants: A person who knowingly and with the intent to defraud an insurer files a statement of claims containing any

false, incomplete or misleading information commits a felony.

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 Louisiana, Maine and Tennessee Resident Applicants: Any person who knowingly and with the intent to defraud any insurance company

or another person, files a statement of claim contain 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, subject to criminal prosecution and civil penalties. Insurance benefits

may also be denied.

Notice to Minnesota Resident Applicants: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against

an insurer is guilty of a crime.

Notice to Nebraska Resident Applicants: Any person who knowingly presents false information in an application for insurance or viatical settlement

contract is guilty of a crime and may be subject to fines and confinement in prison.

Producer’s E&O Application

Notice to Nevada Resident Applicants: Pursuant to NRS 686A.291, any person who knowingly and wilfully files a statement that contains any false,

incomplete or misleading information concerning a material fact is guilty of a felony.

Notice to New Hampshire Resident Applicants: Any person who, with the purpose to injure, defraud or deceive any insurance company, files a

statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided

in RSA 638:20.

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 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.

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 (365:15-1-10, 36 §3613.1).

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 Utah Resident Applicants: For your protection, Utah law requires the following to be included in this application: Any person who knowingly

presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits,

or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and

confinement in state prison.

Notice to 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 include imprisonment, fines and denial of insurance benefits.

Notice to Vermont 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 act, which may be a crime and may subject such person to criminal and civil penalties.

Notice to Applicants in 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 act, which is a crime and may subject such person to criminal and civil penalties.

Producer’s E&O Application

Clearance Procedures

Please read the following section carefully

Clearance has the simple purpose of ensuring that the insured production is not vulnerable to litigation. You should ensure that:

• If the insured production carries any risk of libel, or a related legal problem, it is cleared; and

• All rights necessary to production, exhibition, and distribution in all media are secured before you fill in this form, or will be as soon as practicable. We must

be informed of any rights problems related to material included in the insured production, as soon as you become aware of them, and you must seek advice

on such problems from your own attorneys.

Accordingly, you and your attorneys should be sure before first exhibition of the insured production that:

1 All necessary rights have been obtained, covering domestic and foreign territories, including any extensions and renewals, for all literary material

(other than original and unpublished material) contained in the insured production. If full copyright is not obtained, any limitations and/or

reservations must be notified to us. If you are acquiring the insured production as a completed work (such as a pick-up of a motion picture) rights

must also be secured covering the completed work. The origin of all works on which the insured production is based must be traced and cleared

in order to ascertain that you have all the required rights in the work.

2 Written agreements must exist between you and the creators, authors, writers and owners of all material, including quotations from copyrighted

literary works, film, television, and audio clips, clips of pre-existing music, featured copyrighted props such as maps, etc, used in the insured

production, authorizing you to use the material in the insured production (except in the case of approved ‘fair dealing’). All agreements should

include a waiver of so-called ‘moral rights’.

3 If the subject matter of the insured production is potentially defamatory, or for any other reason legally contentious, it has been cleared by a

suitably qualified libel attorney, as has any ‘fair use’ and all recommended changes have been made.

4 In the case of fictional characters, a full cast script clearance check has been carried out, also of business names, etc and again, all

recommended changes have been made.

5 All contracts and releases must give you the right to market the insured production for use in all media and markets (e.g. DVD, video cassette,

digital format, internet etc.). In particular, any gaps in respect of underlying rights must be notified.

6 Synchronization and performance licenses must be obtained from the composer or copyright owner of all music used in the insured production.

Licenses are unnecessary if the music (and its arrangement) is in the public domain. Licenses must also be obtained from the owners of

recordings for the use of previously recorded music.

7 If the insured production contains any film clips, you have obtained authorization to use the film clip from the owner of the clip who has the right to

grant such authorization and have obtained authority from the owners of and contributors to the film clip e.g. underlying literary and musical rights,

owners, actors, and musicians etc. All releases must give you the right to edit, add to and/or delete any or all of the material supplied by the

releasor.

8 You must be sure that you or any of your partners or directors have not received any unsolicited submissions of any literary or dramatic material,

programme ideas, formats or storylines from any third parties which are similar in content or style to the insured production. If you have, you must

have a process for dealing with them and quit claims must be obtained where appropriate.

9 Any problems relating to the insured production which are not known at the time of completing this application form must be notified to us as soon

as they arise.

10 Any bonus material, interviews or outtakes included on a DVD or any other media version of the production must go through the same clearance

procedures as the insured production.

11 Any uses of copyrighted material in its renewal term must be authorized by persons or entities entitled by statute to renew.

12 All contracts, releases, grants of rights of every kind (including all prior grants in your chain of title) must authorize you to use the acquired

material in your production and to assign or sublicense it in any form.

The above clearance procedures are not exhaustive, nor do they cover all situations which may arise, given the great variety of productions. You and your attorneys

must continually monitor the insured production at all stages, and in light of any special circumstances, make certain that the insured production contains no

material which could give rise to a claim.

Producer’s E&O Application

Applicant Warranties and Representations

The applicant hereby warrants and represents:

1 That the information supplied herein is in all respects true, and material to the issuance of an insurance policy, and that no information has been

omitted, suppressed or misstated; and

2 That Applicant and its counsel has supplied Company with all information required to be furnished pursuant to the Clearance Procedures, and to

the extent such information is not known at the time of the application, such information will be furnished in writing to the Company as soon as

known.

3 Applicant will use best efforts to procure from third parties, from whom it obtains material for the productions to be insured, written warranties and

indemnities against all claims arising out of any use of such material.

4 Applicant and its counsel will use diligence to determine whether any portrayal, matter or materials used in the production to be insured violates

the right of any person or entity, and, where necessary, applicant will obtain from such person or entity, the right to use the same in connection

with the Insured production.

If pursuant to (2) above, information is hereafter furnished to the Company, Company shall have the right to limit the insurance coverage at its discretion.

This application and all attachments will be attached to, and form part of, any policy which may be issued as a result of this application. The signing of

this applicant does not bind the Applicant or the Company to complete the Insurance unless and until a Policy of Insurance is issued in response to this

application. All exclusions in any policy, which may be issued by Company, shall apply regardless of any answers of statements in this application.

Applicant understands that the limit of liability and deductibles under any policy, which may be issued by Company, shall include both loss payment and

claim expense, as defined in the policy.

Signature

The undersigned is a duly authorized representative of the Applicant and hereby acknowledges that reasonable inquiry

has been made to obtain the answers herein which are true, correct, and complete to his/her best knowledge and belief.

Applicant Signature

& Title:

Date:

(Duly authorized representative, by and on behalf of the Applicant)

To be completed by your Insurance Broker:

Insurance Company(s) Applied to: Insurance Broker: License Number:

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