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Home Obama care Sign In Contact Us info@g1g.net 408-286-1111 ext 106 408-997-7890 CA Lic# 0697055   Sign In   User Name11     Password   New User Forgot password? News CEO Zain Jeewanjee Interview on WomenNow TV   DICE/Annual Production Please answer all questions to prevent a delay in processing your quote request. If you have any questions call us at 800.257.7718 for help or fax at 408.997.7890 Contact Information Company Name: Business Entity: -----Entity Type----- Corporation Individual Joint Venture LLC (Limited Liability Company) LLP (Limited Liability Partnership) Non-Profit Partnership Trust Other Proprietorship Communities Company Address:       (street)         (City) ---Select a state--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (zip)       Contact Person: Telephone: Fax: Cell Phone: Email Address: Qualification Questions Any: Stunts,Pyrotechnics, Aircraft, Boats, Animals, Race, Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns, Rap Music? Yes No Any Insurance Cancelled or Declined in past 3 years(not applicalble in Missouri) Yes No If yes, explain Any losses in past? Yes No If yes, Total Amount of losses Production Details Number of Productions for upcoming 12 months by category   Animation: Music Vedio: Commercial/Promotional/Sales Video: Photography Shoot: Documantry/Interviews/Biography: Pick-up Shoot: Editing/Trailer: Pre/Post Production: Educational/Instructional/Training: PSA/Public Access Program: Feature Film: Reality Based TV Show: Independent Feature: SAG Production: Industrial/Corporate Video: Short Film: Infomerical: Spec Production: Miscalleneous Production: TV Pilot/Series/Specials: Total Aggregate Budget for All shoots: Average duration in days per production: Maximum budget per single shoot: Cities and states of shooting location: Coverage Options Coverage Start Date:   Coverage End Date:   Property Rented Equipment Limit: $ Owned Equipment Limit: $ Props, Sets, Wardrobe Limit: $ Negative Film/Faulty Stock: Extra Expense: Office Contents: Third Party Property Damage: General Liability Occurance/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 Inusred/Certificates of Insurance: Include Exclude City Certificates: Include Exclude Waiver of Subrogation: Include Exclude Hired and Non-Owned Auto Liability: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Physical Damage $125,000 per vehicle, $500,000 aggregate Include Exclude Workers Compensation Number of Cast: Number of Crew: Number of Volunteers: Payroll W-2: Payroll 1099: Payroll Deffered: Payroll Other: Payroll Company Name(if any): Officer 1 Name and Title:             (Name)                    (Title) Officer 2 Name and Title:             (Name)                    (Title)

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