WFG - Certificate of Insurance Request

CERTIFICATE OF INSURANCE REQUEST

BROKER SUBMISSION
CERTIFICATE OF INSURANCE REQUEST OVERVIEW

This is an application only. It does not constitute an insurance policy. Insurance shall become effective only upon the issuance of a policy or written binder specifically authorized by the company or agency. Quotations are based upon the information provided in the application. The applicant warrants the information provided is accurate, true and complete.

ELIGIBILITY

To be eligible for Winnipeg Film Group insurance:
- Applicant must be a Director, Producer or Creator of this production and have complete artistic control and own all underlying rights in order to fill out this application!
- Applicant must have attachable documents detailing a shoot schedule, synopsis, budget and a cast and crew list!
- Applicant must be an aspiring or a practicing independent filmmaker either on a part-time or on full-time basis!
- Applicant must be a member in good standing with the Winnipeg Film Group!
- Applicant must be a Manitoba resident!
- Applicant must pay the $350 application fee!
- Applicant must be over the age of 18! If an applicant is under the age of 18, a guardian, parent or teacher must fill out and be responsible for this application.
INSTRUCTIONS

Please ensure you have all the appropriate submission documents and necessary information for your submission prior to beginning to fill out this form. Once you have all the needed documents and information gathered, the process of filling in this submission form should take approximately 20 minutes. Please ensure you have sufficient time to complete the form before beginning.

* Fields with an asterisk MUST be filled in, or you will not be allowed to submit the form. If you are having difficulty on pressing the "submit" button, please review each field and ensure all mandatory fields have been completed and mandatory documents uploaded.

QUESTIONS?

For further information and details about our certificate of insurance program, please contact:

Dylan Baillie Technical Coordinator
(204) 925-3456 ext 101
dylan@winnipegfilmgroup.com

Applicant Information
Name of Insured / Company / Trade Name*
First and Family Name / Company or Trade Name
Date of Birth / Date of Incorporation:*

MonthDayYear
Date
Confirm Eligibility*

I am over 18 years old.I am a Manitoba resident.I paid the Winnipeg Film Group $500 application fee.I am the Director, Creator or Producer of this production.I am a member in good standing with the Winnipeg Film Group.I have four uploadable documents for shoot schedule, synopsis, budget and cast and crew list.I am an aspiring or a practicing independent filmmaker either on a part-time or on full-time basis.
How many years have you been working in filmmaking? *
Is filmmaking your profession? *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

List All of the Additional Insured (if applicable)
Name:
Address:
Why?:
Name:
Address:
Why?:
Name:
Address:
Why?:
Name:
Address:
Why?:
Name:
Address:
Why?:

Filming Locations
Name of Location / Property Owner:*
If applicable.
Location Address:*
Name if applicable.
Name of Location / Property Owner:
If applicable.
Location Address:
Name if applicable.
Name of Location / Property Owner:
If applicable.
Location Address:
Name if applicable.
Does this location require a certificate of insurance?*

YESNO
Does the City of Winnipeg or Province of Manitoba require a certificate?*

YESNO

Insurance Requirement
Limit of Liabilty:*
Select dollar amount above.
Previous Insurer:
Name if applicable.
Premium Paid:
Enter a dollar amount, if applicable.
Claims or Loss History:
Enter a dollar amount, if applicable.
Do you require coverage for rented equipment?*

YESNO
Where/Who are you renting equipment from?
Please separate each entity/individual with a comma (WFG, Whites, Midcan...)
What is the replacement value of the equipment being rented from the Winnipeg Film Group?
Replacement cost of other rented equipment?
If not applicable, type N/A
Where will the equipment be kept while not in use?
If not applicable, type N/A
Describe the security measures for the stored/secured equipment that will be in place overnight?
If not applicable, type N/A
Do you require coverage for rented equipment?

YESNO

Required Documents to Submit
"1. Checked Items Document": (this upload is for any checked off item(s) in this application. This document needs to break down all particulars and provide details about each checked off item above.)

Upload a File
PDF, DOC or DOCx only Cancelof
"2. Shoot Schedule"*

Upload a File
PDF, DOC or DOCx only Cancelof
"3. Synopsis" *

Upload a File
PDF, DOC or DOCx only Cancelof
"4. Cast and Crew List"*

Upload a File
PDF, DOC or DOCx only Cancelof
"5. Total Balanced Budget"*

Upload a File
PDF, DOC or DOCx only Cancelof

Review and Submit
PLEASE READ THIS CAREFULLY BEFORE SUBMITTING

I/We hereby declare that the answers and declarations above, whether in my own hand or not, are true and that I/We warrant that no material fact has been withheld or misstated and agree that should a policy be issued this Application form will be attached to and form part of the policy and will form the basis of the contract with the insurer. I/We agree that answers and declarations shall constitute material warranties of any policy issued. I/We further understand that the insurer may declare any policy issued void in the event of any false statement, misrepresentation, omission or concealment in the Application form whether made intentionally, innocently or accidentally. I/We have been advised and consent to any information that may be perceived as personal information for collection, appropriate use, and disclosure of to third parties.
Please select to complete your online submission.*

I have carefully reviewed all items on this form. I am ready to submit my application for Certificate of Insurance.
Enter Message as Shown*
Date of Submission:

MonthDayYear
Provide the date that you are submitting this application.
Submitted by (Name):*
Provide the name of the individual filling out this application.
Thank you!
Should be Empty:

CERTIFICATE OF INSURANCE REQUEST

Thank you!