Rio Grande Insurance

Production Company (or Individual) Contact Information

Qualification Questions:

Any: Stunts, Pyrotechnics, Aircraft, Boats, Animals, Race Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns, Life Gangster Rap Music, Hard-Core/Soft-Core Porn? (If Yes, please describe in comments, below)		Yes		No
Any Unprotected or working, open heights above 15 feet off the ground? (If Yes, please describe in comments, below)		Yes		No
Any employees supplied to or from an employee leasing operation or payroll service (like a PEO)? (If Yes, please describe in comments, below)		Yes		No
Is coverage required outside of the U.S. and Canada? (If Yes, please describe in comments, below)		Yes		No
Please Confirm that only one production can be covered by a single short term production policy, if the policy is issued? (If Yes, please describe in comments, below)		Yes		No
Have you had any prior productions with any losses of any kind? (If Yes, please describe in comments, below)		Yes		No

Production Details

Title of Production
Type of Production
Budget (Gross Total Production Cost)	$
Brief Description/Synopsis of Shoot
Cities & States of Shooting Locations

For Music Videos Only

Type of Music
Music Decade
Artist Name

Key Personnel - At least one executive producer or producer must be listed. Driver's License number and state are required for all

Role	First & Last Name	Drivers License #	DL State of Issue	Country of Residence

Coverage Options

Effective Day of Coverage
Expiration Day of Coverage

Inland Marine Coverages

Rented Equipment Limit	$
Owned Equipment Limit	$
Props, Sets, Wardrobe Limit	$
Negative Film/Faulty Stock/Hard Drives (Limit equals the budget, up to $250,000)		Include		Exclude
Extra Expense (see coverage definitions here)		$10,000		$25,000
		$50,000		$100,000
		declined
Third Party Property Damage (Care, Custody & Control)		$250,000		$500,000
		$1,000,000		$1,500,000
		$2,000,000		declined
General Liability Coverages (MUST select one)
Per occurrrence/aggregate limit		$1,000,000/$1,000,000
		$1,000,000/$2,000,000
		$2,000,000/$2,000,000
		$3,000,000/$3,000,000
		$4,000,000/$4,000,000
		$5,000,000/$5,000,000
Blanket Additional Insureds/Certificates of Insurance	Already Included in Short Term Single Production Package
City Certificates		Include		Exclude
Waiver of Subrogation (Waiver of transfer of rights)		Include		Exclude
Hired & Non-Owned Auto
Liability		$1,000,000
		$2,000,000
		$3,000,000
		$4,000,000
		$5,000,000
		declined
Physical damage (limit is per vehicle/aggregate)		$125,000/$500,000
		$250,000/$500,000
		declined
Workers Compensation
Is Workers comp required by SAG?		Yes		No
Number of Shoot Days
Number of Full Time Cast & Crew
Number of Part-Time Cast & Crew
Payroll: W-2, 1099, Deferred, Other (explain)
Payroll Company Name (if any)
Names & Titles of Prod. Co. Officers to EXCLUDE

Please enter any additional comments, such as a fifth automobile, fifth driver, RV or motorcycle, different limits on comprehensive v collision, or clarification/more information on items above. If any car is not registered in your name, indicate why: