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ENTERTAINMENT PRO INSURANCE
   Motion Picture, Television, Theatrical, Music, Broadcasting and Special Events   
 
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Step Two: Review and Submit
Step Three: Finish
Welcome to Short Term Productions EZ-Quote from Entertainment Pro Insurance.
For fast service on your commercial accounts complete the form below and hit the “Step Two” button. Your submission will be electronically delivered to the next available Commercial Lines Underwriter.
 
  CONTACT INFORMATION
Name Insured:
  
Entity Type:  
Country of Residency (If Individual):
Country of Residency (All others):
Primary Address (No PO Box):
Mailing Address (If different to primary):
Contact Person:
Phone / Fax:
E-mail Address:
  
Website:
Year Business Established:
    QUALIFICATIONS QUESTIONS
Will the production include any Hard-Core or Soft-Core pornography?:
Will the production include any live gangster rap music?
Will any production activities take place outside of the U.S. and Canada?:
Any employees supplied to or from an employee leasing operation (i.e. PEO)?
Confirm your understanding that if coverage is provided, only one production will be covered by the policy(s) issued:
Any unprotected or open heights above 15 feet?:  
    INSURANCE HISTORY
LOSSES    
 
Any losses in the past 3 years? (If yes, provide details) :
Policy Type  / Line of Business Date of Loss Description Amount of Loss
PRIOR COVERAGE
 
Any prior insurance? (If yes, provide details) :
Policy Type Carrier Policy # Expiration Date Premium
CANCELLED or DECLINED INSURANCE (not applicable in MO)
 
Any insurance declined or cancelled in the past 3 years?
  If yes, provide details:
   PRODUCTION DETAILS 
        Working Title:
  Type of Production:
  Gross Production Cost:
  Number of Episodes (If applicable):
  Production Start Date:
  Production End Date:
  Shooting Locations(s) - Cities & States:
  Synopsis:
   FOR MUSIC VIDEO ONLY 
Type of Music:
Music Decade:
Artist Name:
   PRODUCTION PERSONNEL 
      Enter the key personnel (executive producer, producer, director, etc.)
At a minimum, either the executive producer or producer must be listed.
First & Last Name Personnel Role Drivers License # State of Issue Country of Residence
Executive Producer
Producer
Director
   STUNTS and/or HAZARDOUS ACTIVITIES  
  Will the production include any stunts, pyrotechnics, aircraft, boats, animals, race tracks, race courses, helicopters, motorbikes, snowmobiles, ATVs, blanks, squibs, guns or other hazardous activities?:
  If yes, the information below is required for each stunt/hazardous activity:    
  STUNTS    
 
Type of Stunts:
Aerial Scenes Water Scenes Falls Precision Diving
Fight Scenes Weapons Animals Recreational Vehicles
 
Detailed Description of Stunt:
Date(s) of Stunt:
Stunt Coordinators/Professionals, if any:
Licensed?:
Permits  
Are permits required?
Have they been obtained?
Describe precautions taken for the safety
of the public, participants and property:
Any cast members involved/in close proximity:
If vehicle(s) involved:  
# of vehicles:
Maximum speed
Any collisions, explosions:
  ANIMAL COVERAGE
 
Type of Aminal and breed if applicable:
Value of Animal:
Where will animal be housed during/after filming:
Who is responsible during transport:
Days of filming:
Number of scenes:
Any replacements for the animal and can
they substitute at all times:
  REQUIRED NOTES AND ATTACHMENTS
 
Detailed synopsis of stunt:
 
  • Attach resume of stunt coordinator/pyrotechnician, permits:
  • Certain stunts/hazardous activities are ineligible.
  • Certain coverages (such as workers compensation) may not be available
    for productions that include stunts/hazardous activities.
  
   COVERAGE OPTIONS
  General Liability    
  Occurrence / Aggregate Limit:
  Blanket Additional Insured/Certificate of Insurance:  
  City Certificates:  Include    Exclude  
  Waiver of Subrogation  Include    Exclude  
     
  Inland Marine    
  Rented Equipment (Camera, Lighting, Sound, etc.)  
Values over 600k require a formal resume.
  Rented Props, Sets, Wardrobe:  
  Owned Equipment, Propet Sets, Wardrobe:  
  Negative Film, Videotape $ Digitalized Image:  
  Faulty Stock, Camera & Processing: Same as Negative Film  
  Third Party Property Damage:  
  Extra Expense:  
  Office Contents:  
     
  Automobile    
  Hired & Non-Owned Auto Liability:
  Waiver of Subrogation:  Include    Exclude   
  Hired & Non-Owned Auto Pyhsical Damage
(per vehicle/aggregate limit): 		 
       
  Workers Compensation (available in CA, NY, FL, TX, NC, TN, NV, IL, CO)
  Workers Comp required by SAG?    
  Waiver of Subrogation?  Include    Exclude   
    If included, provide cert holder name/address 
       
  Number of Shoot Days:  
  Payroll Company Name (if any):  
       
  Payroll    
 
Classification   # Full Time # Part Time Payroll (W-2, 1099, Deferred, Other)
Actors  
Crew  
Clerical  
Other (describe)
       
  Listing of All Officers (to exclude from workers comp)
 
First & Last Name Date of Birth SSN Title
Actors  
Crew  
Clerical  
Others (describe)  
       
ADDITIONAL COMMENTS:  
   
 
FOR AGENT USE ONLY
Insurance Agency Name:
Agent Contact Person:
Agent Contact Person Email:
Agent Contact Phone Number:
 
 
FRAUD STATEMENT

Any person who knowingly and with intent to defraud any insurance company or another 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 and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.
 
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