Your Name

Business Name

Phone   

          Fax # 

E-mail Address

Business Address

Studio Location
if different from above.

 Status

Individual            Partnership         Corporation         Other

Interest in the    Premise

Tenant             Owner-Occupant

Current/Prior Insurance

Losses in the last 3 years

Check here if none

 Payment Plan Desired

Annual    Four-pay       Six-pay      Ten-pay    (Note: $6.00 fee added each payment)

 Square Feet occupied by
   you

 Building Construction

    ie., wood frame, brick, etc

 Building Occupancy

  Single            Multiple

 Building 75% sprinkler
  protected

Choose Yes or No yes no

 Building built in the year

     Number of Floors 

 Building over 25
   years old

If building is more than 25 years old, have electrical, plumbing and heating systems and surfaces (roof,siding, parking lot, etc.) been inspected by a qualified contractor or inspection service?
Choose Yes or No Yes No

   In what year were the following systems last updated?

                Electrical        Plumbing    Heating        Roof
 

  Smoke Detectors

No Yes                           If Yes, are they hardwired  No Yes

  Fire Extinguishers

0 1 2 3 4 5 6 7 8 9 10 +                           Fire Alarm No Yes         Type     None Local Silent Central Station    

  Burglar Alarm

No Yes             Type   None Local Silent Central Station

  Security Guard Service

No Yes

  Surge Protectors on
    Computers

No Yes

  Dead Bolts

No Yes

  Barred Windows

No Yes

In what year did you start this business?
 

How many years of experience do you have in photography?
 

How many years have you been at this location?
 

Have you ever filed for bankruptcy?

No Yes                            if yes, in what year 

What percent of your work is on location?
 

Total number of employees
 

   Full Time    Part Time

What is your specialty (i.e., advertising, editorial)

Annual gross sales
 

Do you conduct any other business?

no yes      if yes, occupation and company name 

 $     OWNED CAMERA EQUIPMENT: All-risk, worldwide coverage for your cameras and accessories. Coverage is on a stated-value basis, meaning you should insure each item for the full amount required  to replace it. For example, if you would replace a Canon EOS 30D by buying it new but would replace your old Hasselblad 500C/M by going to the used market, indicate the appropriate acquisition costs on  your schedule. 

 $     RENTED AND BORROWED CAMERA EQUIPMENT: At your option, insure equipment which you rent or borrow from others. Coverage is available on a blanket basis at limits of $2,000, $5,000, $10,000,$20,000, $25,000 or $30,000.

 $     STUDIO/OFFICE CONTENTS & COMPUTER EQUIPMENT:  All-risk coverage for such items as darkroom equipment, studio  furnishings, general office contents and computer equipment. The policy automatically  provides a limit of $10,000. Please indicate if you desire higher limits.


  LOSS OF BUSINESS INCOME: Pays you net income and normal operating expenses while you restore  your business after a covered loss. Business income protection applies more to studio photographers than to location photographers. Coverage is automatic up to the actual loss sustained for a 12-month period.        
  

  EXTRA EXPENSE: Covers the additional costs, such as rental of studio space, in the event   that your space is damaged.

          
    ACCOUNTS RECEIVABLE: Pays you amounts due from your customers that you are unable to collect as a result of covered loss to your records of accounts receivable. The policy automatically provides a limit of $25,000.

   $   none 5,000 10,000 20,000 25,000           TEMPORARY CUSTODY COVERAGE: Insure property of others while in your custody, for up to fourteen days. This benefit is  extremely valuable to advertising and fashion photographers who may be using expensive clothing or consumer products as the subject matter of  their photographs. Temporary Custody Coverage is available on a blanket basis at limits of  $5,000, $10,000, $20,000 or $25,000.

   $         PORTFOLIOS AND VALUABLE PAPERS: Insure the cost to reproduce your portfolios 
 (assuming you have the original images) in the event of theft or destruction by a covered loss. Also covers the portfolio case. Please indicate if you wish higher limits.

   $  None 1,000 2,500             EQUIPMENT RENTAL REIMBURSEMENT: Covers the cost to rent equipment while yours is being repaired or replaced as a result of theft or other covered loss. Limits available are $1,000 or $2,500.

   $   GENERAL LIABILITY INSURANCE: Protection for your acts, and those of your assistants, against bodily injury and property damage claims. The policy automatically provides a limit of $1 million. Please indicate if you wish higher limits.

   HIRED AND NON-OWNED AUTO: Provides liability-only coverage for your business for claims involving assistants personal  vehicles or vehicles you rent or hire. This coverage is excess over any primary coverage which the owner of the vehicle might have