Short Term Production Insurance Application

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Errors & Omissions Application

Please fill out this application with as much detail as you can so that we can provide you with the most accurate price possible.

Customer Information
What type of entity is this insurance going to be for?*
What is the name that the insurance will be under?*

If you do not have a company, the name on the policy needs to match the name you are using for your vendors, permit offices or any other contracts that you have.
Address (No PO Boxes)*
Street AddressCityStateZIP Code
Contact Person*
FirstLast
Phone*
Email*
Enter EmailConfirm Email
How many employees do you have?*
Any prior insurance?*
- 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:*
Any insurance declined, cancelled or non-renewed that provided the same or similar coverage as the insurance sought?*
- Yes
- No
Please provide an explanation.*
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 any invasion of privacy or false light, IP infringement, defamation; or breach of contract arising out of the alleged submission of any ideas, story line, or script?*
- Yes
- No
Please provide an explanation.*
Does the production include any pornographic materials, ride alongs, hidden cameras, pranks and consumer voting or is it an animated theatrical release?*
- Yes
- No

Do you have a U.S. based attorney with 5 years or more relevant entertainment insurance experience performing the clearances for this production?*
- Yes
- No
An attorney doing clearances allows us to provide quotes from a wider variety of companies at a lower cost.
CLEARANCE INFORMATION
Have you obtained a title report for this production?*
- Yes
- No
Is the name or likeness of any actual living person used, portrayed or identifiable in the Named Production?*
- Yes
- No
Do you have the appropriate releases to use the footage with the identifiable living person?*
- Yes
- No
Please provide a description of the scenes with identifiable person(s)*
Is the name or likeness of any actual deceased person used, portrayed or identifiable in the Named Production?*
- Yes
- No
Do you have the appropriate releases to use the footage with the identifiable deceased person?*
- Yes
- No
Please provide a description of the scenes with identifiable person(s)*
Is the production based on an underlying work?*
- Yes
- No
Please confirm the following by checking each box*
- You are not aware of any similar format or concept
- No similar format or material has been submitted to you at any time
Please confirm the following by checking each box*
- Copyright reports have been obtained
- No ambiguities, gaps or problems in the chain of title
- The chain of title of all works on which the production is based has 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
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
Have you obtained a written agreement from all performers or persons appearing in your production consenting to their appearance?*
- Yes
- No
Will any film clips, TV clips or photographs be used in the productions?*
- Yes
- No
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?*
- Yes
- No
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, including: Recording and synchronization Performing rights? Right to distribute for all forms of distribution contemplated (home video, etc.)*
- Yes
- No
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
Have you or any of your agents been unable to obtain or been refused an agreement or release after having: Negotiated for any rights in literary, musical or other materials? Negotiated for release from any persons in respect of any material incorporated in the production?*
- Yes
- No
Please explain why you were unable to obtain an agreement/release from the above.*
MERCHANDISING OPTIONS
Is coverage desired for Merchandising for this Production?*
- Yes
- No
Have all necessary consents and licenses been obtained in respect of any associated merchandising?*
- Yes
- No
Will appropriate trademark 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
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?*
- Yes
- No
Please provide details regarding any loss or claims*
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?*
- Yes
- No
Please provide details regarding any problems likely to result in a loss that you are aware of.*
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

PRODUCTION INFORMATION
What is the exact title of the production?*
Please choose the production type.*
What type of music?*
Please choose the nature of the production.*
What type of work is this?*
Name of Author(s):*
Title(s):*
Date(s) of Publication:*
What is the budget of the production?*

Numbers only, no dollar signs. We will need a budget top sheet that matches this number exactly.
How many minutes is this production?*
Production Synopsis*

Please provide a short plot outline of the production.
Anticipated Release Date*
How many episodes are there?*
How many minutes are each episode?*
DISTRIBUTION INFORMATION
How will this production be distributed?*
- 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.
What medium will be used for distribution?*
- Cable/Satellite/Wireless
- DVD/Videotape
- Internet
- Radio
- Television
- Theatrical Release
- Theatrical Stage
- Other
Will there be bonus material?*
- Yes
- No
Will bonus material use same clearance precedures as the rest of the production?*
- Yes
- No
KEY PERSONNEL
Name of Producer*
FirstLast
Name of Executive Producer*
FirstLast
Name of Script Writer*
FirstLast
ATTORNEY INFORMATION
Firm Name*
Attorney Name*
Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Have you and/or your attorney read and agreed to exercise due diligence to insure that the ‘Clearance Procedures’ attached are followed?*
- Yes
- No

Additional Insureds

If you have the name, address and any special wording that is required for a distributor, financier or other party that needs to be added to the policy, you can list them here.
I have an additional insured that needs to be added to this policy.*
- Yes
- No or not right now (can be added later)
Most of the time the distributor or network that the production is appearing on requires that they be listed as additional insured. If you have a sample contract we can adjust the policy conditions to match those requirements.
Name of Additional Insured*
Address*
Street AddressCityState / Province / RegionZIP / Postal CodeCountry
Please provide any special wording required by this entity.
Coverage Options

Please note that the list of coverage options below are not available for all policy types. We will do our best to provide all requested coverage combinations.
Media Liability Limit*
How many years does this policy need to be?*
- 1 Year
- 2 Years
- 3 Years
Retention*
Coverage Basis*
- Claims Made
- Occurrence with Rights Period Endorsement
- Occurrence without Rights Period Endorsement
Claims made policies only cover claims that are made while the policy is active. This is the standard policy type and is less expensive to obtain.
Title Coverage*
- Include
- Exclude
If you request title coverage we will need a title search report to include it. If the title search report has a lot of hits on it, the underwriters might require a legal opinion letter from a qualified entertainment attorney as well.
Additional Insured Endorsement*
- Include
- Exclude
Additionally Insured protects the named entity from lawsuits arising from content that is in your production. Distributors require this, as well as some managing agents, sales managers etc.
What effective date do you want this policy to go into force?*

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