PHOTOPAC INSURANCE APPLICATION

1. Name of Applicant: *
2. Mailing Address: *
Telephone Number: * Fax Number:    
3. Policy Term: From : To :
4. Location to be Insured:      1 :
Construction of Building:     Square Footage : # of Stories :
Protection:     Sprinklered:       Alarm Type:       Local:
Monitored Stn Alarm:     Distance to Fire Hydrant:     Distance to Fire Hall:
Location to be Insured:       2 :
Construction of Building:     Square Footage : # of Stories :
Protection:     Sprinklered:       Alarm Type:       Local:
Monitored Stn Alarm:     Distance to Fire Hydrant:     Distance to Fire Hall:
5. Type of Photography:
6. Territory of Operations : North America Worldwide
If worldwide coverage is required, a Supplementary Form must be completed
7. (a) Are you involved in:       (i) Underwater Photography: Yes     No
(ii) Aerial Photography: Yes     No
(iii) Hazardous Stunts Yes     No
(b) If the answer is yes, please provide additional information:
     
8. Do your operations include web site design: Yes     No
If yes, attach a sample client release form.
9. Have you had any insurance claims in the past five (5) years Yes     No
If yes, give full details of losses below
Date of Loss Type Amount
10. Details of Applicant:

Year Business Started: Estimated Annual Gross Sales: $

Present Insurer :
Policy Number :  


Supplementary Form


To be completed only if worldwide coverage is required
Percentage of travel outside of North America :
Purpose of travel :
Frequency of travel :
Usual Destination :
Do you travel with Equipment: Yes     No
Maximum replacement cost of Equipment traveling with you: $
Precautions taken to protect Equipment/other property:
Method of transportation of Equipment::