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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