Short Term Production Application

CERTIFICATE HOLDERS

(PLEASE LIST ALL THE NAMES AND ADDRESS OF THE LOCATIONS AND RENTAL HOUSES THAT REQUIRE TO BE NAMED AS A CERTIFICATE HOLDER)

Certificate #1 Name

Certificate #1 Address

Certificate #1 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

Certificate #2 Name

Certificate #2 Address

Certificate #2 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

Certificate #3 Name

Certificate #3 Address

Certificate #3 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

Certificate #4 Name

Certificate #4 Address

Certificate #4 Type Of Certificate Holder (I.E. RENTAL HOUSE, LOCATION, ETC.)

NOTE: Please send a list with additional Certificate Holders if necessary

PLEASE REVIEW THE FOLLOWING TERMS

Coverage CANNOT be CANCELLED once BOUND. Minimum Premiums and Fees are FULLY EARNED and NON-REFUNDABLE upon binding (ordering) your insurance policy.
There may be an Additional Premium due for any changes made after the policy is bound.
Coverage is only valid for ONE project. Multiple projects require multiple policies or one Annual policy, which must be quoted separately.
Coverage is only valid within the United States. I understand that if I have international activities, I will have to purchase a foreign production policy.
This quoted policies will not include Cast Coverage , Errors & Omissions (the Content or Media Liability of your Film/Project), or any other coverage that was not requested to be quoted on this application. A field left blank will be assumed to mean that you do not want that coverage.
A Broker Fee, Policy Fee and/or Administrative Fee may be charged by Athos Insurance Services for the placement and administrative services provided. All fee amounts will be listed and disclosed on the quote. This fee is fully earned upon binding coverage.
I verify that all the information provided on this application is true and accurate to the best of my knowledge and that I have read and accept the terms above. Misrepresentation of information may make my coverage null and void.
I understand that it is my responsibility to provide Athos Insurance with any insurance requirements I have signed or agreed to, before purchasing any policies. I acknowledge that failure to provide Athos with these requirements may prevent me from receiving the most proper insurance policies and can result in additional premiums due to satisfy requirements after policies have been purchased.
I understand that this application is just a starting point to apply for insurance and may result in additional questions from Athos Insurance, in order to receive better quote options.
If I applied for Rented Equipment From Others coverage, I understand this limit is a shared limit of ALL equipment rented from ALL equipment owners and/or rental houses combined. If I rent more than my policy limit, it's my responsibility to contact Athos to increase this maximum limit BEFORE the rental occurs.
If your total equipment limits need to be changed, you can revise your quote before purchase OR make changes after you’ve purchased your policy.
I have reviewed the Replacement Cost Valuation & Policy Limits Acknowledgement, which states: When entering values for Rented equipment and/or Rented Props, Sets and Wardrobes please use the REPLACEMENT COST value including SALES TAX. “Replacement Cost” is the cost to replace the gear with new or like-kind in quality equipment today.

(Please type in your full name)

I HAVE READ AND ACKNOWLEGED THE ABOVE

DATE