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Additional Insurance Coverage
Students: Read and Complete This Entire Form
GENERAL INSTRUCTIONS:
Use the TAB key or MOUSE click to move from field to field.
CAUTION: Using the ENTER key will automatically submit the form.

PLEASE REVIEW YOUR SUBMISSION BEFORE CLICKING "SUBMIT"
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.

Is this request for General Liability Limits, Rental Equipment Limits or Both?
General Liability Rental Equipment Both General Liability & Rental Equipment

GENERAL LIABILITY ADDITIONAL LIMITS

Please answer the below questions if this is a
request for additional limits for General Liability!

The Location Address for these additional limits?:

Detailed description of your shoot?:


Describe additional limits needed:


Are there any Hazardous Activities taking place during this shoot? Yes No

If Yes, please describe these Hazardous Activities in detail!:


RENTAL EQUIPMENT ADDITIONAL LIMITS

Please answer the below questions if this is a
request for additional limits for Rental Equipment!

Name of the Rental House needing these additional limits?:

Describe additional limits needed:


List of Equipment, complete with the replacement value of each item?:
Example:
Tripod - $75.00
Light Stand - $45.00
Camera, Model TX234 - $20,000.00


Total replacement value of above listed equipment?: $

What is the exact date you are picking up the equipment?:

What is the exact date you are returning the equipment?:

How many total days will you have the equipment in your possession?:

How is the equipment being used?:


Where is the equipment being used?:


What security measures have you put into place to secure and protect the equipment?:


Where is the equipment being stored when not in use?:


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