Motion Picture Package Application
MOTION PICTURE / TELEVISION / DICE PRODUCERS - APPLICATION
1. Name of Production Company:
2. Title of Production (if applicable):
3. Mailing Address:
4. Physical Location Address:
5. Name(s) of Principal(s):
6. Number of Years of Experience: (Attach Bio/Resume if Available)
7. List of Prior Projects:
8. Describe Prior Losses (Or Enter None):
9. Primary Contact Name: Tel No. Email
10. Type of Production(s):
Documentary Films Commercials / Infomercials
Webisodes / Interstitials Corporate Videos
Educational / Instructional Videos Music Videos
Motion Picture Feature Films TV Movies
TV Pilot / Special TV Series # of Episodes
Movie Trailers Animation / CGI
Other
11. Number of Productions per Year: Total Budget per Year:
12. Maximum Cost Any One Production:
13. Any Post Production Work Done for Others?: Yes No If Yes What %
14. If a Single Project, what is Total Budget? MUST ATTACH AT LEAST TOP SHEET OF BUDGET
15. Principal Photography Dates (If Applicable):
16. Producer: Director:
17. Source of Financing:
18. Completion Bond Required? Yes No Completion Bond Company:
19. Filming Location(s) including Filming Dates at Each Location(s):
20. Story / Synopsis:
21. Cast Insurance Required? Yes No Number of Cast Members
22. Names and Roles of Cast Members:
23. Does any Cast Member have any film projects immediately following this project?
24. The Production involves (check all that applies):
Use of Animals Underwater Filming
Motorcycles Special Vehicles
Airborne Crafts Waterborne Crafts
Railroad Cars or Equipment None of the Above
If any of the above are checked:
Provide details of involvement of any Cast Member and ATTACH
Pyrotechnics (Explosions, fire) Complete Supplemental Application
Stunts or Hazardous Activities Complete Supplemental Application
25. Check Coverages Requested / Needed:
Commercial General Liability Blanket Additional Insured Endorsement
Waiver of Subrogation
Hired & Non-Owned Auto Liability Enter Cost of Hire:
Workers Compensation Cast & Crew Payroll:
FEIN Clerical Payroll:
Payroll Co Name:
All Officers Name(s), Title(s), Ownership %: Exclude from WC Cover? Yes No
Name Title % Ownership Incl/Excl
Umbrella / Excess Liability Enter Limits:
Foreign Exposures General Liability
Which Country (ies): Hired & Non-Owned Auto
Workers Compensation
Completed by:
(Authorized Representative)
Date:
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