Short Term Production Application

PRODUCTION EQUIPMENT

(EXCLUDING AUTOS OR VEHICLES)

RENTED PROPS, SETS & WARDROBES Do you need to insure any rented or borrowed props, sets, or wardrobes?

SELECT YES OR NO

Yes No

NOTE:THE ABOVE LIMITS ARE THE COMBINED TOTAL REPLACEMENT COST VALUE OF ALL EQUIPMENT AND/OR PROPS RENTED FROM ALL RENTAL HOUSES / INDIVIDUALS AT ANY ONE TIME, NOT THE COST OF THE RENTAL EQUIPMENT

RENTED PRODUCTION EQUIPMENT Do you need to insure any rented or borrowed production equipment?

SELECT YES OR NO

Yes No

Pick-Up Date Of All Rented

Return Date Of All Rented Equipment

The Rented Equipment Limit is the total replacement cost value of the equipment you are renting from all owners/rental houses combined. If you do not have the exact limit, please feel free to provide an estimated total.

CONTINUING RENTAL FEES (IF YOU HAVE A CLAIM, THIS CONTINUES PAYING YOUR RENTAL INCOME TO THE PERSON/ORGANIZATION WHO IS RENTING THEIR EQUIPMENT TO YOU, UNTIL THE CLAIM IS CLOSED)

Yes No

$2,500 (+$27) $5,000 (+$54) $10,000 (+$81) $25,000 (+$135)

Do you have any one item over $150,000 you are renting?

Yes No

Replacement Cost Over 150k Details

Make	Model	Replacement Cost Value	How will this be used?	How will this item be secured overnight?	How will this item be transported?	Will this item be left unattended in a vehicle?	Action

Will any of your equipment be going above or under water? (What does this mean? Watch the video here.)

Yes No
IF Yes, what is the maximum rented equipment that will go above or under water?
Where will the equipment be stored overnight?
Will you park all vehicles with production equipment in a secured location such as a gated parking lot or security guarded lot?

Yes No
At this location, will there be a monitored alarm system (one that is connected to a monitoring service that can dispatch the police and/or fire department?)

Yes No
Will you have a watchman, intrusion alarm or monitored Closed Circuit Television at your storage location?

Yes No
How will the equipment be secured?
Do you need coverage for transit (transporting and/or shipping of equipment)?

Yes No
Please select one of the following deductibles (What does this mean? Watch the video here.)

$250 $500 $1000 $2,500
Do you have any pre-existing damages on any of the equipment or items you are looking to cover on this policy?

Yes No
IF Yes, Please describe in detail.

If you had to fix the damages today, how much would it cost to fix everything (feel free to estimate)?
Will you ever take more than $25,000 total equipment to the country of Mexico?

Yes No
Please list the max value you will take to Mexico at any one time

What Cities will you be going to in Mexico?

What location(s) will you be filming at? (types of locations and venue name)

How will the equipment be stored overnight when not in use?

How will the equipment be transported to Mexico?
Will you ever take the proposed covered equipment to a country with US Sanctions?

Yes No
Which countr(ies) on the list will you travel to with your equipment? (please list all countries)
Please answer the following question based on how you plan to store your equipment during this policy term. This information is needed for underwriting purposes. Our policy covers theft from an unattended vehicle, regardless of how you answer the next question.

I Understand

Will you ever leave any of your equipment in a vehicle UNATTENDED?

Yes No
What is the maximum value of equipment left in your vehicle unattended?

How much of the $XXX may be left Unattended OVERNIGHT (maximum amount)?

How often does this happen?

Of the $XXXX of equipment that is left unattended, what is this gear comprised of (i.e. cameras, lenses, grip equipment, etc.)?

What kind of vehicle will you leave your equipment in (please describe in detail)

What security measures will be taken to protect the equipment while left in a vehicle?

Does the equipment being insured have a GPS tracking device?

Yes No

Does the tracking device signal send to a monitored, remote device or security system?

Yes No

Does the vehicle have an alarm system?

Yes No

Does the alarm signal go to a monitored, remote device or security system?

Yes No

Please explain

Please select all that apply to how you may leave your equipment in an unattended vehicle:

I LEAVE MY EQUIPMENT IN AN UNATTENDED VEHICLE...

Only if it's an emergency or rare situation when I cannot store it anywhere else

For short periods of time (less than 30 minutes) including for food and bathroom breaks

For hours at a time, but not overnight

For days at a time, including overnight

All the time, including storing it in my vehicle

Other frequencies

Where will the vehicle be parked when left unattended? (mark all that apply)

City Street

Residential Street

Residential Garage (private home)

Residential Shared Garage (i.e. apartment complex)

Parking Garage:

If you marked “Parking Garage” please also mark all that apply below to the parking garage:

With 24 hour Security Guard and Surveillance

With limited surveillance

Restricted Access (Key Card)

Fenced

Gated

Lighted

Not Guarded

No Lot Attendant

Other:

Other

AUTO LIABILITY

(This is to insure rented or borrowed vehicles used for production purposes, or to fulfil a requirement asking for non-owned hired auto liability)

Please select from the following

I Do Not Need Any Auto Liability or Physical Damage Coverage I will be Renting and/or Borrowing one or more vehicle(s) and need to cover the vehicle I need auto liability to satisfy an insurance requirement, but I will NOT be renting a vehicle

WORKERS COMPENSATION

Would you like to add Worker's Compensation?

Yes No

NUMBER OF CAST MEMBERS

How many are full-time ?

Part time?

NUMBER OF CREW MEMBERS

How many are full-time ?

Part time ?

Total payroll for all cast and crew members excluding owners

NAME OF OWNERS MUST BE LISTED (The below individual(s) will be excluded from Workers Compensation coverage)

Full name

Title

Full name

Title

Full name

Title

Federal ID Number of Corporation or Social Security Number of owner

ACCIDENT MEDICAL COVERAGE

(NOTE: This IS NOT Workers Compensation Coverage. It reimburses medical expenses sustained to cast or crew while participating in the filming operations, excess of any existing health insurance available. If anyone is already covered by Workers Compensation, then they are not eligible for Accident Medical Coverage)

Would you like to add Accident Medical coverage to this policy?

Yes No

Type of project
Description of type of Project
Title of project
Start date of project

End date of project
Total Project Budget

Please list the number of locations you will be filming at
Please provide a synopsis of your film including a description of the types of scenes you will be filming

NOTE:IF YOUR PRODUCTION INVOLVES ANY HAZARDOUS ACTIVITIES OR STUNTS, WE CANNOT QUOTE WORKERS COMPENSATION

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DESIRED INSURANCE COVERAGE GENERAL LIABILITY (Please Select One of Options Below)

OPTION 1

NO GENERAL LIABILITY NEEDED By checking this box, I confirm I am not requesting any general liability insurance and will not need to name any entities or vendors as additional insured.

OPTION 3

PRODUCTION LIABILITY - THIS IS GENERAL LIABILITY FOR ALL OTHER PURPOSES SUCH AS LOCATIONS, PERMIT OFFICES, AND RENTAL HOUSES Liability for Locations & to Rent Equipment—By checking this box, I am requesting a quote for production liability insurance, Including location liability for film permits. This also includes liability to rent equipment.

SELECT YES OR NO

COVERAGE

Yes No

GENERAL LIABILITY

$1,000,000 / $1,000,000 $1,000,000 / $2,000,000 $1,000,000 / $3,000,000 $1,000,000 / $4,000,000 $1,000,000 / $5,000,000

Yes No

Increased Damage To Premises Rented To You ($100,000 is included)

Yes No

CITY / SPECIAL CERTIFICATES (I.E. FILM PERMIT OFFICE)

Yes No

WAIVER OF SUBROGATION

Yes No

PRIMARY AND NON-CONTRIBUTORY WORDING

Yes No

Would you like to add $10,000 of Medical Expense Coverage for Spectators? (Spectators are bystanders who are neither cast nor crew members)

EXCESS LIABILITY

Excess liability adds additional liability limits on top of your general liability limit. For example, if you have a $1M per occurrence and $1M aggregate limit for general liability coverage, adding a $1M excess liability policy will provide a total coverage of $2M per occurrence and $2M aggregate general liability limits.

SELECT YES OR NO

COVERAGE

Excess Limit Desired

Yes No

EXCESS LIMIT

PRODUCTION / PROJECT INFORMATION

Title Of Film / Project

Type Of Production

Description of type of production

Number Of Locations For Film/Project

Number Of Shoot Days

Locations For Film/Project (City and state)

Please list the type of location(s) you will be renting (i.e. a studio, a residence, a restaurant, a park, etc.)

My filming location will be (please select one):

Closed off to the general public (i.e. a closed room and set)

Open area that cannot be sectioned off from the general public (i.e. a park, on the streets, or an open event)

Total Project Budget

PRODUCTION DATES (Include Days you’re picking up & returning EQUIPMENT)

Start Date

End Date

KEY PRODUCTION CONTACT (Must be Producer or Executive Producer) Full Name Of Producer Or Executive Producer

Title

Driver License Number

Driver License State Of Issuance

How Did you Hear About Us?

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CERTIFICATE HOLDERS

(PLEASE LIST ALL THE NAMES AND ADDRESS OF THE LOCATIONS AND RENTAL HOUSES THAT REQUIRE TO BE NAMED AS A CERTIFICATE HOLDER)

Certificate #1 Name

Certificate #1 Address

Certificate #1 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

Certificate #2 Name

Certificate #2 Address

Certificate #2 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

Certificate #3 Name

Certificate #3 Address

Certificate #3 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

Certificate #4 Name

Certificate #4 Address

Certificate #4 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

NOTE: Please send a list with additional Certificate Holders if necessary

PLEASE REVIEW THE FOLLOWING TERMS

Coverage CANNOT be CANCELLED once BOUND. Minimum Premiums and Fees are FULLY EARNED and NON-REFUNDABLE upon binding (ordering) your insurance policy.
There may be an Additional Premium due for any changes made after the policy is bound.
Coverage is only valid for ONE project. Multiple projects require multiple policies or one Annual policy, which must be quoted separately.
Coverage is only valid within the United States. I understand that if I have international activities, I will have to purchase a foreign production policy.
This quoted policies will not include Cast Coverage , Errors & Omissions (the Content or Media Liability of your Film/Project), or any other coverage that was not requested to be quoted on this application. A field left blank will be assumed to mean that you do not want that coverage.
A Broker Fee, Policy Fee and/or Administrative Fee may be charged by Athos Insurance Services for the placement and administrative services provided. All fee amounts will be listed and disclosed on the quote. This fee is fully earned upon binding coverage.
I verify that all the information provided on this application is true and accurate to the best of my knowledge and that I have read and accept the terms above. Misrepresentation of information may make my coverage null and void.
I understand that it is my responsibility to provide Athos Insurance with any insurance requirements I have signed or agreed to, before purchasing any policies. I acknowledge that failure to provide Athos with these requirements may prevent me from receiving the most proper insurance policies and can result in additional premiums due to satisfy requirements after policies have been purchased.
I understand that this application is just a starting point to apply for insurance and may result in additional questions from Athos Insurance, in order to receive better quote options.
If I applied for Rented Equipment From Others coverage, I understand this limit is a shared limit of ALL equipment rented from ALL equipment owners and/or rental houses combined. If I rent more than my policy limit, it's my responsibility to contact Athos to increase this maximum limit BEFORE the rental occurs.
If your total equipment limits need to be changed, you can revise your quote before purchase OR make changes after you’ve purchased your policy.
I have reviewed the Replacement Cost Valuation & Policy Limits Acknowledgement, which states: When entering values for Rented equipment and/or Rented Props, Sets and Wardrobes please use the REPLACEMENT COST value including SALES TAX. “Replacement Cost” is the cost to replace the gear with new or like-kind in quality equipment today.

(Please type in your full name)

I HAVE READ AND ACKNOWLEGED THE ABOVE

DATE

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