Wintemute Insurance - Video and Production Quote Form

Video and Production Insurance Quote Request Form

Please enter the following information, click submit and we will gladly respond with short term production insurance quotation:

A red asterisk - * - Indicates required information.

Full Contact Name

Full Business Name

Mailing Street Address

Mailing City

State

Zip Code

E-Mail Address

Reply By

Telephone

Fax

Contact's Driver's Licence Number , State:

Contact Person's Role

Type of Entity

Please answer the following questions to determine if the production qualifies for this program:

Underwriting Questions:

Does the production include any of the following:
Pyrotechnics, BoatsRace Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns?

Yes No

Is coverage required outside of the U.S. and/or Canada?

Yes No

Does the production include any of the following:
      * Hard or soft-core pornography?
      * Live Gangster rap music?
      * Are any employees supplied to or from an employee leasing operation?
      * Will any actors be working at unprotected or open heights above 15 feet?

Yes No
Yes No
Yes No
Yes No

Will any of the production take place outside of the United States or Canada? (If yes please enter all locations in notes section.)

Yes No

Are there any Stunts? (If yes please describe in notes section.)

Yes No

Any Animals? (If yes please describe in notes section.)

Yes No

Vehicles or Aircraft? (If yes please describe in notes section.

Yes No

Claim History

* Any prior production with any losses of any kind?

Yes No

* Any production losses in the last three years?

Yes No

* Any Insurance declined or canceled in the last three years

Yes No

Click HERE for coverage definitions.

Total Budget

Title of Production

Production Type

Location Street Address or Intersection

Location City State Zip Code

Complete description of shoot

Amount of rented equipment coverage desired: $

Unscheduled Owned Equipment $

Amount of props, set & wardrobe

Extra expense coverage desired

Third party property damage desired

$25,000 faulty stock & negative film No Yes

Desired Liability Limit

City or other special certificate required? No Yes

Waiver of subrogation required? No Yes

Automobile coverage options

Worker's compensation coverage desired? No Yes (Available in CA, FL, NC, NY & TX Only)

If yes, SAG requirement? No Yes

	Cast	Crew	Volunteers	Shoot Days
# of People
	W-2	1099	Deferred	Other
Amount of Payroll

Dates coverage requested:

From

Additional Notes