Name of Applicant:*
Name of Business:
The Applicant is:* Select An Individual A Sole Proprietor An LLC A Partnership A Corporation Other
Other Applicant Entity:*
Email:*
Phone:*
Premises Street Address:*
Premises City:*
Premises State:* Alabama Arizona California Colorado Connecticut District of Columbia Georgia Idaho Illinois Indiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nevada New Jersey New Mexico New York North Carolina Ohio Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin
Premises Zip Code:*
Year your premises was built:*
Construction Type:* SELECT frame concrete brick
Mailing Address CHECK IF DIFFERENT
Mailing Street Address:*
City:*
State:* Alabama Arizona California Colorado Connecticut District of Columbia Georgia Idaho Illinois Indiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nevada New Jersey New Mexico New York North Carolina Ohio Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin
Zip Code:*
Website:*
Do you rent autos(production vehicles, vans, motor homes, grip trucks)?* Yes No
Do you rent your camera equipment or your studio to others?* Yes No
Annual Rental Income:*
Years under current business name:*
Previous experience within your industry:* SELECT 1-4 Years 5-10 Years 11+ Years
Brief description of your business:*
Do you hire crew members?* Yes No
Average Crew Size:* Max Crew Size:*
Do you work outside of the US?* Yes No
List the country you worked in or plan to work in:*
Do you have another business?* Yes No
Name of Business:*
Description of Operations & Services:*
Separately Insured?* Yes No
Have you ever had a business insurance claim?* Yes No
Description of Loss:*
Do you have insurance now?* Yes No
Who is your current carrier?* SELECT Berkley Chubb Farmers Fireman's Fund Hartford Hiscox New York Marine One Beacon Philadelphia State Farm Unknown Other
Other carrier name:*
Estimated Annual Gross Revenue:*
Estimated Gross Production Costs:* SELECT $0 - $75,000 $75,000 - $200,000 $200,000 - $500,000 $500,000 - $1,000,000 $1,000,000 & Above
Average number of jobs per month:*
Average cost per job:* SELECT $0 - $15,000 $15,000 - $50,000 $50,000 - $100,000 $100,000 - $300,000 $300,000 - $500,000 $500,000 & Above
Max cost per job:* SELECT $0 - $15,000 $15,000 - $50,000 $50,000 - $100,000 $100,000 - $300,000 $300,000 - $500,000 $500,000 & Above
I have answered the above questions truthfully and to the best of my knowledge. I understand that any intentional misrepresentation or fraudulent information used to purchase this insurance may result in declination, cancellation, or denial of my insurance coverage* I agree
Comments:
Is it okay to send documents to you via email?* Yes No
How did you hear about TCP?*
I would like TCP to contact me regarding my Auto Insurance I would like TCP to contact me regarding my Home or Renters Insurance I would like TCP to contact me regarding my Health/Life/Disability/401K Insurance
Submit To:* SELECT Amanda@TCPinsurance.com BarbaraW@TCPinsurance.com Cathi@TCPinsurance.com Natasha@TCPinsurance.com Rich@TCPinsurance.com Sales@TCPinsurance.com
Verification