ACE Advantage®
Multimedia Liability
Renewal Application
NOTICE
The Limits of Liability stated in the Policy are reduced, and may be exhausted, by Claims Expenses.
Claims Expenses are also applied against your Retention, if any. If you have any questions about
coverage, please discuss them with your insurance agent.
INSTRUCTIONS
Completion of this application may require input from your organization’s risk management, information technology,
finance, and legal departments. Additional space may be needed to provide complete answers.

Please type or print answers clearly.

Answer ALL questions completely, leaving no blanks. If any questions, or part thereof, do not apply, print
“N/A” in the space.

Provide any supporting information on a separate sheet using your letterhead and reference the applicable
question number.

Where the question requires a Yes or No answer, answer each question with respect to both the Applicant
and its Subsidiaries.
This form must be completed, dated and signed by an authorized officer of the Applicant.

UNDERWRITERS WILL RELY ON ALL STATEMENTS MADE IN THIS APPLICATION.
ALL BOLDED TERMS USED IN THIS APPLICATION SHALL HAVE THE SAME MEANINGS AND
DEFINITIONS AS CONTAINED IN THE ACE MULTIMEDIA POLICY UNDER WHICH THE APPLICANT IS
SEEKING INSURANCE.
AS USED HEREIN, THE TERM “APPLICANT” SHALL HAVE THE SAME MEANING AS THE TERM
“INSURED”, AS CONTAINED IN THE ACE MULTIMEDIA POLICY UNDER WHICH THE APPLICANT IS
SEEKING INSURANCE.
ADDITIONAL INFORMATION REQUIRED
Please submit the following information with the application:
a. Samples of the Applicant’s standard contracts, releases, work orders, or license agreements used with
employees, independent contractors, third party distributors, licensees, authors, clients, talent, and/or
advertisers;
b. List of any new Scheduled Media which the Applicant currently uses or anticipates using over the next
twelve (12) months; and
c. Most recent annual report of Applicant if it is a privately held company.
1.
Applicant Name:
Business Address:
Business Type:
Corporation
Joint Venture
Partnership
Limited Liability Company
Business Description
Year Established:
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Number of Principals, Partners, Directors, Officers, and Employees:
Total Number of Employees:
URL Addresses for All Public-Facing Websites:
2.
Subsidiaries:
List all Subsidiaries for which insurance coverage is desired. Please provide percentage ownership by Applicant
and each Subsidiary.
Subsidiary Name
Percentage of
Ownership
%
Acquisition or
Formation Date
Multimedia Services
%
%
%
3. Within the past twelve (12) months, has the Applicant:
a. Changed Name?
Yes
No
b. Changed Ownership Structure?
Yes
No
c.
Yes
No
Yes
No
Purchased or acquired another entity?
d. Merged or consolidated operations with another entity?
If any of 3a. – 3d. are answered “Yes”, please attach a summary of all relevant transactions.
4. In any of the transactions listed in Question 3, did Applicant assume the liabilities of the acquired, merged or
consolidated entity?
Yes
No
N/A
If “Yes”, attach details of the liabilities assumed.
5. Is the Applicant providing any new Media Services or utilizing any new Scheduled Media for which coverage is
sought.
Yes
No If “Yes”, please describe in detail and attach a separate sheet if necessary
6. Within the past twelve (12) months, have any changes been made to the written clearance procedures utilized by
the Applicant prior to the dissemination of Matter?
Yes
No
If “Yes”, please indicate what changes
have been made and provide a copy of the updated clearance procedures.
7. Financial & Business Information:
Indicate the Applicant’s fiscal year end date:
/
Year
(month/day)
Revenues
Percentage NonUS Revenues
Prior Fiscal Year
Current Fiscal Year
Projected Next Fiscal Year
PF-22807a (01/10)
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FRAUD WARNING STATEMENTS
ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA APPLICANTS: Any person who knowingly
presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies.
DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or
fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was
provided by the applicant.
FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurer,
files a statement of claim or an application (or any supplemental application, questionnaire or similar document)
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be
presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer,
broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of,
or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit
pursuant to an insurance policy for commercial or personal insurance which such person knows to contain
materially false information concerning any fact material thereto; or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act.
KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which
is a crime.
MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a
denial of insurance benefits.
MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and willfully presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for
an insurance policy is subject to criminal and civil penalties.
NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND
CRIMINAL PENALTIES.
NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information, or
conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty cont to exceed five thousand dollars
and the stated value of the claim for each such violation.
OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance
fraud.
PF-22807a (01/10)
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OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or
deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or
misleading information is guilty of a felony.
OREGON APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or
another person, files an application for insurance or statement of claim containing any materially false information,
or conceals information for the purpose of misleading, commits a fraudulent insurance act, which may be a crime
and may subject such person to criminal and civil penalties.
PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company
or other person files an application for insurance or statement of claim containing any materially false information
or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.
TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO ALL APPLICANTS:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
ANOTHER PERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING
ANY MATERIALLY FALSE INFORMATION, OR CONCEALS INFORMATION FOR THE PURPOSE OF
MISLEADING, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY SUBJECT
SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
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NOTICE TO APPLICANTS. PLEASE READ CAREFULLY
BY SIGNING THIS APPLICATION, THE APPLICANT, ON BEHALF OF ALL PROPOSED INSUREDS,
WARRANTS TO THE COMPANY THAT ALL STATEMENTS MADE IN THIS APPLICATION AND
ATTACHMENTS HERETO ABOUT THE APPLICANT, ITS SUBSIDIARIES, AND THEIR OPERATIONS ARE
TRUE AND COMPLETE, AND THAT NO MATERIAL FACTS HAVE BEEN MISSTATED, OMITTED,
SUPPRESSED, CONCEALED, OR MISREPRESENTED IN THIS APPLICATION OR ITS ATTACHMENTS .
THE APPLICANT UNDERSTANDS AND AGREES THAT IF, AFTER THE DATE OF THIS APPLICATION AND
PRIOR TO THE EFFECTIVE DATE OF ANY POLICY BASED ON THIS APPLICATION AND ATTACHMENTS,
ANY OCCURRENCE, EVENT OR OTHER CIRCUMSTANCE SHOULD RENDER ANY OF THE INFORMATION
CONTAINED IN THIS APPLICATION INACCURATE OR INCOMPLETE, THEN THE APPLICANT SHALL
NOTIFY THE COMPANY OF SUCH OCCURRENCE, EVENT OR CIRCUMSTANCE AND SHALL PROVIDE THE
COMPANY WITH INFORMATION THAT WOULD COMPLETE, UPDATE OR CORRECT SUCH INFORMATION.
ANY OUTSTANDING QUOTATIONS MAY BE MODIFIED OR WITHDRAWN AT THE SOLE DISCRETION OF
THE COMPANY.
COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. THE APPLICANT’S ACCEPTANCE OF THE
COMPANY’S QUOTATION IS REQUIRED BEFORE THE INSURANCE MAY BE BOUND AND A POLICY
ISSUED. THE APPLICANT UNDERSTANDS AND AGREES THAT THE COMPANY, IN PROPOSING TO
PROVIDE INSURANCE, HAS RELIED ON THIS APPLICATION AND ALL ATTACHMENTS, AND THAT THIS
APPLICATION AND ALL ATTACHMENTS ,ARE (1) MATERIAL AND THE BASIS OF THE CONTRACT WITH
THE COMPANY, AND (2) DEEMED TO BE A PART OF THE POLICY TO BE ISSUED AS IF PHYSICALLY
ATTACHED THERETO. THE APPLICANT HEREBY AUTHORIZES THE RELEASE OF CLAIMS INFORMATION
FROM ANY PRIOR INSURERS TO THE COMPANY.
THE UNDERSIGNED OFFICER OF THE APPLICANT CERTIFIES AND WARRANTS THAT HE/SHE IS DULY
AUTHORIZED TO EXECUTE THIS APPLICATION ON BEHALF OF THE APPLICANT AND ITS SUBSIDIARIES.
Applicant’s Signature:
_____________________________________________
(Must be signed by an Officer of the Applicant)
Print Name and Title
/
/
Date (Mo./Day/Yr.)
PF-22807a (01/10)
© 2010
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FOR FLORIDA APPLICANTS ONLY:
Agent Name:
Agent License Identification Number:
FOR IOWA APPLICANTS ONLY:
Broker:
Address:
FOR ARKANSAS, MISSOURI AND WYOMING APPLICANTS ONLY:
THE APPLICANT UNDERSTANDS AND ACKNOWLEDGES THAT THE POLICY FOR WHICH IT IS
APPLYING CONTAINS A DEFENSE WITHIN LIMITS PROVISION WHICH MEANS THAT CLAIMS EXPENSES
WILL REDUCE THE POLICY’S LIMITS OF LIABILITY AND MAY EXHAUST THEM COMPLETELY. SHOULD
THAT OCCUR, THE APPLICANT SHALL BE LIABLE FOR ANY FURTHER CLAIMS EXPENSES AND
DAMAGES.
Applicant’s Signature:
_____________________________________________
(Must be signed by an Officer of the Applicant)
Print Name and Title
/
/
Date (Mo./Day/Yr.)
PF-22807a (01/10)
© 2010
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