Entertainment – Accident/Medical

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Entertainment - Accident/Medical

Customer Information
What is the name that the insurance will be under (also known as the Named Insured)?*
The name on the policy needs to match the name you are using to execute agreements/contracts with your locations, vendors, permit offices or any other entities you'll be working with. If you do not have an LLC, corporation, partnership or non-profit set up, then please input the name of the individual who will be responsible for producing the film shoot/event.
Address (No PO Boxes)*
Street Address City State ZIP Code
Contact Person*
First Last
Phone*
Email*
Enter Email Confirm Email
Have you purchased an accident medical policy before?*
- Yes
- No
Please provide the policy numbers, premiums and expiration dates of your prior insurance:*
Any prior claims?*
- Yes
- No
Please provide the dates, amounts of the claim(s) and descriptions of what happened:*
What date do you want this policy to start?*
MM slash DD slash YYYY
What date do you want this policy to expire?*
MM slash DD slash YYYY
Please identify the type of operations you will be executing with this policy:*
- Film Production
- Special Event
- Sports Event
What is the title of your production?*
What is the name of the event?*
Please provide a synopsis of the production - a description of the types of scenes that will be shot and/or a summation of the plot.*
Please provide a description of the event you will be producing. Please be sure to identify any and all activities you will be hosting.*
Please identify the specific sports activities that will be covered by the policy, whether there are amateur or professional athletes involved, and if participants will be over or under the age of 18.*
How many locations will you be filming at?*
Please enter a number greater than or equal to 1.
Please confirm that you will not be filming at any jails, prisons, or axe/knife throwing, bow & arrow or gun ranges.*
- Confirmed
What is the name of the venue at which your event will take place?*
What is the venue's address?*
Street Address City State ZIP Code
Please confirm your understanding of the fact that the following activities could NOT be afforded coverage under the policy: Horse Vaulting/Jumping, Trick/Stunt Riding, Equine Racing Exposures, Leasing of Horses, Inflatable Amusement Devices, Corn Cannon, Jumping Pillow, Pumpkin Launching Devices, Carnival Rides, Knockerball/Bubble Soccer, Bungee Devices, Fireworks Sales & Displays, Mechanical Bucking Devices: including Multi Ride Attachments, Permanent & Mobile Rock Wall Structures, Rock Climbing, Security Services Other Than Contracted Law Enforcement Officers, Trampolines, Zip Lines, Ropes Course, Tackle Football, Surfing, Zippy Pets, White Water Rafting, Water Skiing, ATV/UTV, Trackless Trains, Participants of Aerial Activities.*
- Confirmed
Outside of the activities listed in the previous question, will the production include any other stunts, jumps, falls, fight scenes, pyrotechnics, fireworks, aircraft, boats, water-based activities, trains, railroads, military equipment, race tracks/courses, helicopters, hot air balloons, motorbikes, snowmobiles, the use of blanks, squibs, guns (non-firing prop guns do not apply, unless they're being used as a blunt weapon) or weapons (such as knives, swords, clubs, etc.); or any other hazardous activities?*
- Yes
- No
Hazardous activities will not necessarily result in a denial of coverage; but it may affect the cost of the policy. An accident during the execution of a hazardous activity would not be afforded coverage unless the underwriter is well informed on the fact that such an activity will be occurring.
Please advise the stunts or other hazardous activities that will be performed.*
How many people will the policy need to cover (please indicate a number that is more than 1)?*
Please enter a number from 1 to 250.
Please confirm that you will not be obtaining workers compensation coverage.*
Please confirm your understanding of the fact that, if bound, this policy would NOT provide coverage for illness; would NOT respond to lawsuits brought against the Named Insured by employees, contractors, cast, crew or participants; and would NOT be considered an acceptable substitute for workers compensation, should you be required to have that coverage.*
If you will need a policy that will provide the above coverage, you will need to request a quote for workers compensation. Depending on the circumstances, we may or may not be able to accommodate your request.
What limit of Accident Medical Coverage would you like to be quoted for:*
- 50,000
- 100,000
- 150,000
What deductible would you like the policy to have?*
- $250
- $500
- $1000
- $2500
The deductible is the amount of money the insured would be expected to pay out of pocket, should a claim occur.
Please confirm that the information you've supplied on this application is accurate to the best of your knowledge.*
Comments
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