Business Insurance | Hiscox - Series person of interest cast

|General Information |1. |Name of applicant: | |

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| |FEIN #: | |

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| |2. |Applicant’s address: | |

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| |Zip code: | | |Telephone: | |

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| |3. |Email address: | |

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| |4. |Website address: | |

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| |5. |Applicant is: |Corporation |Partnership |Individual |

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| |6. |President: | |

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| |7. |Vice President: | |

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| |8. |Treasurer: | |

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| |9. |Secretary: | |

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| |10. |List applicant’s prior productions: |

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| |Titles |Insurance Carrier |

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| |11. |Production office address: | |

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| | |Phone number: | |

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| |12. |Address to be used on | |

| | |certificate(s): | |

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| |13. |Person to contact for audit: | |

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| | |Phone number: | |

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|Your production details |14. |Title of the production: | |

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| |15. |The production is: |

| | Feature |MOW | Mini series |Series |

| | Pilot/special |Animation | |

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| |If series, number of episodes: | |Length of episodes: | |

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| |Strip | |Number of weeks: | |Length of episodes: | |

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| |Number of episodes per week: | | |

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| |Other: | |

| |Please give details: | |

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| |Running time: | |

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| |Producer: | |

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| |Director: | |

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| |UPM: | |

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| |Coordinator: | |

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| |Production accountant: | |

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| |16. |Story line: |

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| |17. |Production costs: |

| | |Gross production cost |$ |Vehicle cost of hire: |$ |

| | |Below the line cost |$ |Cinemobiles |$ |

| | | | |All other |$ |

| | |Story/scenario |$ |Bond fee |$ |

| | |Post production |$ |2nd run residuals |$ |

| | |Music rights |$ |Insurance |$ |

| | |Contingency |$ |Bond fee: |$ |

| | |Insurable Production Cost |$ |Other |$ |

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| | |Any optional items to be insured? (i.e. story, interest, finance charges, etc. along with amounts) |

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| |18. |Are there any deferments? If so, please explain in detail: |

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| |19. |Source of financing: | |

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| |20. |Bond company: | |

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| |21. |Release or distribution organization: | |

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| |22. |Start date of principal |/ / | |

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| |23. |Completion date of principal: |/ / | |

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| |24. |Start date of pre-production: |/ / | |

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| |25. |Estimated date of protection print: |/ / | |

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| |26. |List all locations of filming: |

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| |27. |Number days principal photography |Location / days at each |

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|Insurance coverages |28. |Coverage |Limits |Deductible |

| | |Cast |$ |$ |

| | |Media (negative and faulty stock) |$ |$ |

| | |Extra expense |$ |$ |

| | |Production equipment |$ |$ |

| | |Props, sets and wardrobe |$ |$ |

| | |Third-party property damage |$ |$ |

| | |Production office property |$ |$ |

| | |Money |$ |$ |

| | |Cast |$ |$ |

| | |Auto physical damage |$ |$ |

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|Optional coverages |29. |Family cast | |Undeclared cast | |Errors and judgment | |

| | |Library stock | |Animal extra expense | |Civil and military authority | |

| | |Civil commotion | |Imminent peril | |Seizure or quarantine | |

| | |Strike | |Utility failure | |Animal morality | |

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| |Fine arts, jewelry, and furs valued over $10,000 per item/ $50,000 per production. | |

| |Please provide full details: | |

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| |Watercraft valued over $25,000 (if needed specify amount and complete details on supplemental questionnaire). | |

| |Resumption of operations (TV, DICE and Wrap Up’s only). | |

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| |30. |Extended pre-production cast insurance |

| | |Names and date of birth |Date |Limit of liability |

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| |31. | Cast insurance |

| | |Names and date of birth |Role |Start date |

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|Other product information |32. |Lab/ post production facility name and location: | |

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| |33. |Cutting rooms or on-line editing facilities: |

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| |34. |How and how often negative shipped: | |

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| | |Dailies viewed: | |

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| | |Any special effects/ processing to be negative: | |

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| |35. |List cameras to be used: |

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| |36. |Any medical facilities provided or medical professional employees contracted? |

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| | |Value of equipment: |Rented $ |Owned $ |

| |37. |Any one of a kind/special type of equipment used? |Yes No |

| | |If Yes, provide details and values: | |

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| |38. |Value of props, sets and wardrobe: |Rented $ |Owned $ |

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| | |Estimated time needed to reconstruct sets: | |

| | |What other location/facilities would be immediately available? |

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| | |Length of time and costs: | |

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| |39. |Any special sets construed? If so, please provide details and values: |

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| | |Length of time and costs: | |

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| | |Protection of property: | |

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| |40. |Where is equipment kept when not in use? | |

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| |41. |Security: | |

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| | |Any ‘one of a kind’ fine arts/jewelry/antiques? If so, please provide details and values. |

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| |42. |Any ‘one of a kind’ fine arts/jewelry/antiques? If so, please provide details and values. |

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| |43. |Description of location/facilities used where values are in excess of $1 million: |

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| |44. |Does production anticipate any of the following activities? |

| | |Use of animals | |Use of aircraft | |Use of watercraft | |

| | |Underwater filming | |Use of railroad cars and equipment | |Use of special vehicles | |

| | |Use of motorcycles | |Pyrotechnics | |Other | |

| | |Other | |Stunts or hazardous activities | | |

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| | |If so, please complete the supplemental questionnaire in full. |

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| |45. |Has the applicant had any production insurance declined in the last five years? |Yes No |

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| | |If Yes, please list insurance carrier and why? | |

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| |46. |List any losses the applicant has had over $10,000 in the last five years: |

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| |Please attach the following information: |

| |copy of budget |

| |script |

| |day of days |

| |complete shooting schedule |

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| Declaration |I declare that this application form has been completed after proper inquiry and, based on this inquiry, I declare the|

| |application contents are true, accurate and not misleading. |

| |I declare that I will immediately notify Hiscox, before any contract or insurance is concluded, of any additional |

| |information that might render the contents of this application untrue, inaccurate, or misleading, or if any new fact |

| |or matter arises which is material to the consideration of this application for insurance. |

| |I declare that I understand and agree that if any of the contents of this application are untrue, accurate, or |

| |misleading, in any material respect, or if I fail to notify Hiscox of additional information that might render the |

| |contents of this application untrue, inaccurate, or misleading, in any material respect, then Hiscox is entitles to |

| |rescind any policy issued pursuant to this application. |

| |I declare that I understand and agree that this application and al materials submitted in connection with this |

| |application are incorporated into and form the basis of any policy issued by Hiscox pursuant to this application. |

| |I declare that by signing this application I am representing and warranting that I am duly authorized to execute |

| |insurance contracts on behalf of the entity applying for this coverage and that all representations (whether verbal or|

| |written) made in connection with this application are made on behalf of and shall be fully binding upon such entity. |

|ALL STATES (UNLESS A STATE-SPECIFIC |NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES |

|FRAUD WARNING APPLIES) |AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE |

| |PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME |

| |AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. |

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|STATE-SPECIFIC |NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY REPRESENTS A FALSE OR FRAUDULENT|

| |CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS |

| |GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. |

| |NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR |

| |INFORMATION TO AN ISNURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE INSURANCE COMPANY. |

| |PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN|

| |INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR |

| |CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A |

| |SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE|

| |DEPARTMENT OF REGULATORY AUTHORITIES. |

| |NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN |

| |INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN|

| |ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY |

| |THE APPLICANT. |

| |NOTICE TO FLORIDA RESIDENT APPLICANTS: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY |

| |INSURANCE COMPANY FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING |

| |INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. |

| |NOTICE TO KENTUCKY RESIDENT APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO DEFRAUD AN INSURANCE COMPANY |

| |OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION |

| |OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT |

| |INSURANCE ACT, WHICH IS A CRIME. |

| |NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR|

| |BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE |

| |SUBJECT TO FINES AND CONFINEMENT IN PRISON. |

| |NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN |

| |INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A |

| |DENIAL OF INSURANCE BENEFITS. |

| |NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT|

| |OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS |

| |GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. |

| |NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFIRMATION ON AN APPLICATION FOR |

| |INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. |

| |NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST |

| |AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILITY OF INSURANCE |

| |FRAUD. |

| |NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH THE INTENT TO INJURE, DEFRAUD, OR DECEIVE |

| |ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE COMPANY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING |

| |INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36 §3613.1). |

| |NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OR A LOSS OR |

| |BENEFIT OR KNOWINGLY PRESENTS MATERIALLY FALSE INFORMATION IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME |

| |AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. |

| |NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER |

| |PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR |

| |CONCEALS FOR THE PURPOSE OF MISLEADING, NFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE|

| |ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. |

| |NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR |

| |MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PENALTIES INCLUDE |

| |IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. |

| |NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER |

| |PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, |

| |CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT |

| |WHICH MAY BE A CRIME ANY MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. |

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| |Signature of authorized representative | |Date (mm/dd/yy) |

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| |Title: | |

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| |A copy of this application should be retained for your records. |

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| |Signature of Producer: | |Producer’s license number: |

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| |Producer’s name: | |Address of Producer: |

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