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Other Potentially Hazardous Exposures
Students: Read and Complete This Entire Form
GENERAL INSTRUCTIONS:
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Distribution of Certificates
This is a SPECIAL INSURANCE REQUEST, it may take an additional one to two weeks to process your insurance, so start early.
PLAN ACCORDINGLY!!
GENERAL PRODUCTION INFORMATION

Have you submitted the "Production Registration Form"?:
Yes  No

If you answered "No" this will redirect you to the proper Production Registration Form.

Original Name of Production:

Director's Name (No nicknames. List name as registered with NYU!):
First Name:
Last Name:
Insurance Contact - Email Address:
Email address must be an NYU issued email.
Must end in @nyu.edu. All others will be rejected, and your form will have to be resubmitted.

Location(s) of Hazardous Exposure(s):


Does this Hazardous Exposure involve?:
Location Equipment Props Other

Please give a detailed description of your shoot:


Please describe, in complete detail, the potentially
Hazardous Exposures you will face during your shoot.:


Describe safety precautions being exercised:



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