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408-286-1111 ext 106
408-997-7890
CA Lic#
0697055
 
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Please answer all questions to prevent a delay in processing your quote request.
If you have any questions call us at 408.286.1111 for help or fax at 408.997.7890
Contact Information
Company Name:
Business Entity:
Company Address:

     
(street)        

(City)


(zip)
 
   
Contact Person:
Telephone:
Fax:
Cell Phone:
Email Address:
Qualification Questions
Is coverage required outside of the US and Canada?:
Yes No
Does the following apply to any vessels used in the production?
Yes No
Vessel used within 50 miles of attachment?
Yes No
Vessel used out of water?
Yes No
Other vessels to be towed?
Yes No
Is there water-skiing?
Yes No
Are there any stunts?
Yes No
Any prior productions with any losses of any kind?
Yes No
Production Details
Type of Production:
Title of Production:
Budget (Gross Production Cost): $
Brief Description/Synopsis of Shoot:
Cities and States of Shooting Locations:
Coverage Start Date:  
Coverage End Date:  
Coverage Options
Number of Vessels:
Vessel Detail:  
Name:
Registration #:
Year:
Length:
Market Value:
Type:
Builder:
Vessel Use
Date of Use:
Use (Operating)
# Vessel Crew:
# Production Crew:
# Days:
Use (Dockside)
# Vessel Crew:
# Production Crew:
# Days:
Place of Attachment:
Locations used:
Navigation Area to be Used:
Vessel Owner
Name of Company/Organization:
Contact Person:
Phone:
Fax:
Owner named as: Additional Insured Loss Payee
Coverage Options
Hull & Machinery: Yes No
Protection & Indemnity: $1,000,000 10,000,000
Wharfinger's Liability: $1,000,000 10,000,000
Tower's Liability: $1,000,000 10,000,000
Charterer's Liability: $1,000,000 10,000,000
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California Lic # 0697055
1494 Hamilton Ave #101, San Jose, CA 95125