Rio Grande Insurance

Production Company (or Individual) Contact Information

Qualification Questions: (All answers REQUIRED)

Any: Live Gangster Rap Music, Hard-Core/Soft-Core Porn? (If Yes, please describe in comments at bottom of page)		Yes		No
Any Unprotected or working, open heights above 15 feet off the ground? (If Yes, please describe in comments at bottom of page)		Yes		No
Any employees supplied to or from an employee leasing operation or payroll service (like a PEO)? (If Yes, please describe in comments at bottom of page)		Yes		No
Is coverage required outside of the U.S. and Canada? (If Yes, please describe in comments at bottom of page)		Yes		No
Please confirm your understanding that only one production can be covered by a single short term production policy, if the policy is issued?		Yes		No
Have you had any prior productions with any losses of any kind? (If Yes, please describe in comments at bottom of page)		Yes		No

Production Details

Title of Production	*REQUIRED
Type of Production (ind. feature, short film, documentary, commercial, music video, etc.)	*REQUIRED
Budget (Gross Total Production Cost, including everything listed below)	$ *REQUIRED
Total Hired + Rented Auto Cost, including cost for all cars, vans, trucks & trailers	$ *REQUIRED
Story or Scenario Cost	$
Music and/or Sound Rights	$
Post Production Costs (post production is not covered on a production policy)	$
Note that Net Insurable Production Costs (NIPC) will be Total Budget less costs of story, rights and post
Description/Synopsis of script	*REQUIRED
Cities & States of Shooting Locations	*REQUIRED

Stunts and special general liability:

Will the production include any of the following: Stunts, pyrotechnics, aircraft, boats, animals, race courses, helicopters, motorbikes, snowmobiles, blanks, squibs, guns, choreographed fights, falls or "precision driving of vehicles" (skidding, collisions, speeding, etc and/or with stunt drivers)? (If Yes, please describe in comments at bottom of page)

Yes

No

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

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

Coverage Options

Effective Day of Coverage
Expiration Day of Coverage
First Day of Principal Photography	*REQUIRED
Last Day of Principal Photography	*REQUIRED

Inland Marine Coverages (note that deductibles are set based on limit requested)

Rented Equipment Limit Minimum Premium: About $325, includes up to the first $100,000	$	(minimum $25,000, if coverage desired)
Equipment owned by the above named production company (owned equipment floater) Limit	$	(minimum $10,000, if coverage desired)
Props, Sets, Wardrobe Limit Minimum Premium: About $321	$	(minimum $25,000, if coverage desired)
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) Minimum Premium: About $333		$250,000		$500,000
This means that you borrow (at no charge) an item from someone to use in the production		$1,000,000		$1,500,000
		$2,000,000		declined
General Liability Coverages (MUST select one) - this coverage is REQUIRED Minimum Premium: $505 for any production less than 11 days of principal photography
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
SPECIAL City Certificates (these are normally not required) Minimum Premium: About $265		Include		Exclude
Waiver of Subrogation (Waiver of transfer of rights, only applies if previously required in a contract you have with someone) Minimum Premium: About $265		Include		Exclude
Hired & Non-Owned Auto
Auto Liability Minimum Premium: About $313 A great coverage! Covers anybody driving any vehicle, any time for a purpose involved with the production. Note this is a liability coverage - covers bodily injury and property damage to 3rd parties, not damage to the vehicles in use with the production		$1,000,000
		$2,000,000
		$3,000,000
		$4,000,000
		$5,000,000
		declined
Hired Auto Physical damage Minimum Premium: About $305		$125,000/$500,000
(limit is per vehicle/aggregate)		$250,000/$500,000
		declined
Workers Compensation Minimum Premium: About $600 (Note: Does NOT cover volunteers)
Is Workers comp required by SAG?		Yes		No
Workers Comp: # of Shoot Days
Workers Comp: # of Full Time Cast & Crew
Workers Comp: # of Part-Time Cast & Crew
Workers Comp: Payroll: W-2, 1099, Deferred, Other (explain below)
Workers Comp: Payroll Company Name (if any)
Workers Comp: Names & Titles of Production Company 10+% Owners to EXCLUDE
Volunteer Accident Coverage Minimum Premium: About $396
Total # of volunteers
Limit, per volunteer:	$25,000 $50,000 $100,000 $200,000 coverage declined
Would you like primary or excess coverage? (primary pays before/with volunteers' health insurance, excess pays only after or if volunteers do not have health insurance)		Primary, if available		Excess
Cast Coverages
Do you want cast accident coverage?		Yes		No
Do you want cast sickness coverage? (requires physician completed forms)		Yes		No
# of cast to cover for above
Do you want cast coverage in pre-production?		Yes		No
Do you want cast coverage in post-production?		Yes		No

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Please enter any additional comments or considerations. If your production includes stunts, animals, blanks, squibs, guns, jumps, driving, water, boats, pyrotechnics, falls, fight scenes or "precision driving of vehicles" (skidding, collisions, speeding, etc and/or with stunt drivers), please describe in detail: