Worker’s Compensation Insurance Application

This application can provide coverage for a U.S. based company going to other countries for film production activities.

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
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:*
Does the production include any Stunts, Pyrotechnics, or Underwater Activities?*
- No
- Yes

Coverage Dates
Coverage Start Date*
Coverage End Date*
General Liability
General Liability
Waiver of Subrogation
- Exclude
- Include
Auto Liability
Hired & Non-Owned Auto Liability
Auto Physical Damage (25K/25K)
- Exclude
- Include
Employers Responsibility
Benefits for Voluntary Compensation-North Americans
Number of Employees from US and/or Canada*
Maximum Number of Employees Per Flight*
Inland Marine
Unscheduled Owned Equipment
Rented Equipment, Props, Sets & Wardrobes
Travel Accident
Guild Members, Non-Guild Members, Aggregate Limit
Guild refers to employees that are part of a Guild, Trade Association or Labor Union. Non-Guild refers to all other employees.
Email

This field is for validation purposes and should be left unchanged.

Customer Information