Insured Name:
Today's Date:
Address:
City/ST/Zip:
Policy/Quote #:
Effective Date:

Limit:

$100,000 Per Occurrence/Aggregate (Standard) Check if an optional limit is desired: $ 250,000 Per Occurrence/Aggregate $ 500,000 Per Occurrence/Aggregate $1,000,000 Per Occurrence/Aggregate

Please answer each of the following questions:

1) Are you a member of the American Society of Media Photographers? Yes No

2) Are your total annual revenues greater than $1,000,000? Yes No

3) What type of photographic services is the insured involved with? Check those that apply:

Advertising Photography     Magazine Photography     "Paparazzi" Photography     Corporate Photography

Model/Fashion Photography     Sports Photography     Editorial Photography     News Photography       (daily or weekly publications)

Studio Photography     Wedding Photography     Other:

4) Please list your top 5 clients:
   
   


5) Based on a percentage of total receipts, how much of the insureds work is subcontracted to others?

6) Within the past five years has the insured been sued or been the subject of claims against them for:
· Infringement of copyright, trademark, service mark, trade name, trade secrets, title, or slogan Yes No
· Defamation, invasion of privacy, or publicity rights Yes No
· False advertising, idea misappropriation, or breach of implied contract Yes No
· Professional acts or omissions Yes No

7) Do you maintain your own photo stock library? Yes No

8) Do you have images of other photographers in your photo stock library? Yes No

If yes, have you obtained an indemnification agreement from the original
Photographer to indemnify you for claims arising from the licensing
of their images? Yes No

9) Have you been refused E & 0 / Professional coverage in the past? Yes No

Please fax a copy of your standard model and/or location clearance releases.


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Thank You!