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CEO Zain Jeewanjee
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DICE/Annual Production
Please answer all questions to prevent a delay in processing your quote request.
If you have any questions call us at 408.286.1111 for help or fax at 408.997.7890
Contact Information
Company Name:
Business Entity:
Company Address:



Contact Person:
Cell Phone:
Email Address:
Qualification Questions
Any: Stunts,Pyrotechnics, Aircraft, Boats, Animals, Race, Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns, Rap Music?
Yes No
Any Insurance Cancelled or Declined in past 3 years(not applicalble in Missouri)
Yes No If yes, explain
Any losses in past?
Yes No
If yes, Total Amount of losses
Production Details
Number of Productions for upcoming 12 months by category  
Music Vedio:
Commercial/Promotional/Sales Video:
Photography Shoot:
Pick-up Shoot:
Pre/Post Production:
PSA/Public Access Program:
Feature Film:
Reality Based TV Show:
Independent Feature:
SAG Production:
Industrial/Corporate Video:
Short Film:
Spec Production:
Miscalleneous Production:
TV Pilot/Series/Specials:
Total Aggregate Budget for All shoots:
Average duration in days per production:
Maximum budget per single shoot:
Cities and states of shooting location:
Coverage Options
Coverage Start Date:  
Coverage End Date:  
Rented Equipment Limit: $
Owned Equipment Limit: $
Props, Sets, Wardrobe Limit: $
Negative Film/Faulty Stock:
Extra Expense:
Office Contents:
Third Party Property Damage:
General Liability
Occurance/Aggregate Limit: $1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $2,000,000
$3,000,000 / $3,000,000
$4,000,000 / $4,000,000
$5,000,000 / $5,000,000
Blanket Additional Inusred/Certificates of Insurance: Include Exclude
City Certificates: Include Exclude
Waiver of Subrogation: Include Exclude
Hired and Non-Owned Auto
Liability: $1,000,000
Physical Damage $125,000 per vehicle, $500,000 aggregate Include Exclude
Workers Compensation
Number of Cast:
Number of Crew:
Number of Volunteers:
Payroll W-2:
Payroll 1099:
Payroll Deffered:
Payroll Other:
Payroll Company Name(if any):
Officer 1 Name and Title:  
          (Name)                    (Title)
Officer 2 Name and Title:  
          (Name)                    (Title)
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California Lic # 0697055
1494 Hamilton Ave #101, San Jose, CA 95125