ACE Advantage®
Multimedia Liability
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 all Scheduled Media which the Applicant currently uses or anticipates using over the next twelve
(12) months;
c. Most recent annual report of Applicant if it is a privately-held company; and
d. Loss runs for the past five years supplied by the Applicant’s previous Multimedia Insurance Carrier.
1.
Applicant Name:
Business Address:
Business Type:
Corporation
Joint Venture
Partnership
Limited Liability Company
Business Description:
Year Established:
Number of Principals, Partners, Directors, Officers, and Employees:
Total Number of Employees:
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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.
Percentage of
Ownership
%
Subsidiary Name
Acquisition or
Formation Date
Multimedia Services
%
%
%
3. a.
Is the Applicant wholly or partially owned by, affiliated with, or controlled by any other entity not listed in
Questions 1 or 2?
Yes
No
b. Does Applicant wholly or partially own, operate, manage, or control any other business or entity not listed in
Questions 1 or 2?
Yes
No
If 3a. or 3b. is answered “Yes”, please explain:
4. Within the past five years, has the Applicant:
a. Changed Name?
Yes
No
b. Changed Ownership Structure?
Yes
No
c. Purchased or acquired another entity?
Yes
No
d. Merged or consolidated operations with another entity?
Yes
No
If any of 4a. – 4d. are answered “Yes”, please attach a summary of all relevant transactions.
5. In any of the transactions listed in Question 4, did Applicant assume the liabilities of the acquired, merged or
consolidated entity?
Yes
No
N/A
If “Yes”, attach details of the liabilities assumed.
6. 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
7. Please list by percentage of revenue a breakdown of the Applicant’s activities as it relates to Media Services:
A. Advertising
% (If not applicable, check box)
Advertisers (If not applicable, check box)
a. Describe the nature of the Applicant’s businesses and the types of products and/or services rendered:
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b. Provide approximate percentage in each of the following categories:
c.
%
Radio
%
Newspapers
%
Internet
%
TV
%
Magazines
%
Catalog/Mail Order
%
Other (describe):
List Advertising agency(ies) with whom the Applicant has a contractual or other business relationship:
d. Does the Applicant operate an in-house advertising agency?
Yes
No
e. Does the Applicant engage in comparative advertising?
Yes
No
f.
Does the Applicant perform any of the following advertising-related services for third parties?
Yes
No If “Yes”, indicate approximate percentage in each class:
Public Relations
%
Games Design
%
Web Site Design
%
Printing Services
%
Mail order or catalog
sales
%
Photo Services
%
Production of Film/TV
%
Broadcasting
%
Musical Services
%
Radio programming
%
Market Research
%
Web Site Hosting
%
Promotion/Sweepstakes
%
Package/Display/Product
Design
%
Media Buying /
Ad Placement
%
Is all content cleared by legal counsel prior to use?
B. Publishing
Yes
No
% (If not applicable, check box)
1. Book Publishing (If not applicable, check box)
Types of books published by the Applicant (Please provide approximate percentage for each of the
following categories).
2. a.
Textbooks
%
Technical
%
History, Biography
%
How-to
%
Religious
%
Celebrity
%
Current biography, or
Autobiography
%
Classics/Social/Political
%
Investigative Reporting /
Exposes
%
Poetry
%
Commentary
%
Other (attach description)
%
Fiction
%
Children’s
%
Newspaper Publishing (If not applicable, check box)
Please indicate the names of each Newspaper distributed or published by the Applicant as well as the
gross annual sales attributable to each such Newspaper:
Name of Newspaper
Date of First
Publication
b. Check primary circulation area:
International
National
Other (attach description)
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Rural
Frequency
Suburban
© 2007
Metro
Circulation
Regional
Annual Sales
Campus
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3. a.
Publications (If not applicable, check box)
Please indicate the names of the newsletters, books, magazines, and other literary monograph,
brochures, directories, screen plays, film scripts, playwrights, and video publications distributed or
published by the Applicant, as well as the gross annual sales attributable to each publication:
Name of Publication
Date of First
Publication
Frequency
Circulation
Annual Sales
b. Do the Applicant’s writers, reporters and editors receive regular training regarding the Applicant’s
media clearance procedures?
Yes
No
c. Are all titles and content cleared by legal counsel prior to publication?
Yes
No
C. Broadcasting and Transmission:
% (If not applicable, check box)
1. Please provide percentage of Applicant’s most recent fiscal year from following activities:
Broadcast/Transmission Activity
Television
Radio
Satellite
Internet
Cable
Wireless
Other (please describe)
%
%
%
%
%
%
%
%
%
2. Please list Applicant’s broadcasting stations and Cable Systems and provide the requested
information.
Station Call
Letters/
Cable
Systems
City/State
AM / FM/ TV/ CABLE
(Please Circle One)
Number of
Listeners/Viewers/
Subscribers
Percent of
Simulcast
Market
Classification
AM / FM / TV / CABLE
AM / FM / TV / CABLE
AM / FM / TV / CABLE
AM / FM / TV / CABLE
AM / FM / TV / CABLE
3. Does the Applicant engage in any type of ”investigative” reporting?
If “Yes”, please describe how sources of information are maintained:
Yes
No
4. Does the Applicant utilize hidden microphones or cameras?
Yes
No
5. Do Applicant’s reporters engage in ride-alongs with law enforcement, any
emergency services or private investigators?
If “Yes”, please provide description of quality control procedures used by Applicant:
Yes
No
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6. Does the Applicant pre-record interview or talk show programs?
Yes
No
7. Does Applicant utilize a delay mechanism for live programming?
Yes
No
8. Advise percentage of the following:
a. Original content created by Applicant
%.
b. Solicited original content created by others (third parties) for Applicant
%.
c. Unsolicited original content created by others (third parties) for Applicant
%
d. Previously published, released, archived content to be republished by Applicant
%.
9. Subject Matter of Programming:
Reality
Live Talk Shows
Education
Sports
Live Broadcasting
Infomercial
Self Help
Adult/Mature
Children’s
Other:
%
%
%
%
%
%
%
%
%
%
D. Electronic Media including the Internet (If not applicable, check box)
1. Indicate type of content Applicant disseminates electronically, including any related digital versions, or
incidental, supplemental or special editions. (Check all that apply)
Software Games
Health/Medical
Archived documents/records
Adult/mature audience
Self-Help/Self Improvement
Movies/Movie Clips
Database
Music/Sound Clips
Directed at children under the age of 13
Directed at persons over the age of 18
Streaming Media
Other (describe):
2. Advise percentage of the following:
a. Original content created by Applicant
%.
b. Solicited original content created by others (third parties) for Applicant
c.
Unsolicited original content created by others (third parties) for Applicant
%.
%
d. Previously published, released, archived content to be republished by Applicant
%.
3. Does Applicant license intellectual property to third parties?
Yes
No
If “Yes”, does the Applicant require indemnification from the third party utilizing the Applicant’s
intellectual property?
Yes
No
Non-Media Related Services (If not applicable, check box)
1. Describe non-media related services Applicant performs for others:
2. Identify the categories of persons and entities for whom the Applicant provide these services:
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3. Briefly, describe Applicant’s five largest jobs or projects during the past five years:
Name of Client
Annual Revenue
Service(s) Performed
4. Average dollar value and length of duration of any service contract? $
5. Largest dollar value and longest duration of any single contract?
$
8. Safeguarding and Clearance Procedures
a. Does the Applicant utilize in-house legal counsel for advice regarding media and
intellectual property law issues?
Does the Applicant utilize outside legal counsel for advice regarding media and
intellectual property law issues? If “Yes”, please provide name, address and phone
number:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If neither in-house nor outside legal counsel is utilized, please explain the procedures
used by the Applicant to evaluate media and intellectual property law issues:
b. Does the Applicant use written clearance procedures prepared and/or recommended by
legal counsel prior to the dissemination of Matter? If “Yes”, please provide a copy of
the clearance procedures.
c.
Does anyone within Applicant’s organization have authority to overrule clearance
procedures recommended by legal counsel?
If “Yes”, please describe who has such authority and scope of such authority:
d. Does the Applicant have procedures in place for responding to third parties’ unsolicited
ideas, books, screenplays, articles, photographs, or other content?
If “Yes”, describe Applicant’s procedures for processing unsolicited ideas, books,
screenplays, articles, photographs, or other content and the procedures the Applicant
uses to obtain licensing and/or ownership rights in such content:
If “No”, does the Applicant advise the third party of its rejection of the unsolicited
material?
e. Does legal counsel review all contracts and quality control procedures used by the
Applicant?
If “No”, please explain procedures used to evaluate the Applicant’s contracts and
quality control procedures:
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f.
Does the Applicant always use a written contract or agreement describing the Media
Services to be provided?
Yes
No
g. Does the Applicant require third party providers of content to assign or license to the
Applicant rights to use the content?
Yes
No
h. Does the Applicant require third party providers of content to indemnify the Applicant for
any intellectual property infringement Claim based upon use of the third party content?
Yes
No
Yes
No
Yes
No
If “Yes”, attach representative contracts, work orders, license agreements, or letters of
agreements used with clients. If “No”, provide detailed explanation regarding how
client relationships are established, managed and maintained:
i.
Describe Applicant’s procedures for acquiring third party intellectual property rights in content:
j.
Describe Applicant’s procedures for responding to requests for the retraction of any content:
k.
Describe Applicant’s procedures for handling complaints regarding the dissemination of content:
l.
Are independent contractors, subcontractors, free-lance or contributing journalists,
writers, photographers, editors, or stringers utilized in gathering, dissemination,
publication, broadcast, or transmission of Matter? If “Yes”, what percentage of
applicant’s total revenues is attributable to work performed by such individuals?
%
m. Does Applicant obtain releases for creative material or talent from employees,
independent contractors, models, contributing journalists, writers, photographers,
editors, stringers, musicians or other third parties supplying Matter or Media Services
to the Applicant?
n. Describe how the Applicant monitors the quality of services performed by independent contractors, including
vendors, subcontractors, free-lance or contributing journalists, writers, photographers, editors, or stringers:
9. Prior Insurance
a. Please provide the following information for any Multimedia Liability Insurance under which the Applicant was
insured during the last five years:
Company
Limit of
Liability
Deductible
Premium
Policy Period
1.
2.
3.
4.
5.
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b. Missouri Residents are not required to answer this question.
Has any Multimedia and/or Media Liability Insurance issued to the Applicant ever been declined, cancelled or
non-renewed?
Yes
No
If Yes, please explain on separate sheet.
10. Claims History
a. After inquiry, do any principals, directors, officers, partners, employees, or independent contractors of the
Applicant have knowledge or information of any actual or alleged acts, errors, omissions, offenses or
circumstances with respect to any Media Services or Multimedia Acts which might reasonably be expected
to give rise to a claim against the Applicant or any proposed insured entity?
Yes
No
If “Yes”, please describe:
b. During the past five years, have any claims or suits been made against the Applicant, or any principals,
directors, officers, or employees of the Applicant with respect to any Media Services or Multimedia Acts?
Yes
No
If “Yes”, please describe:
FRAUD WARNING STATEMENTS
NOTICE TO ARKANSAS, LOUISIANA 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
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NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.
NOTICE TO 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.)
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FOR FLORIDA APPLICANTS ONLY:
Agent Name:
Agent License Identification Number:
FOR IOWA APPLICANTS ONLY:
Broker:
Address:
FOR MISSOURI AND WYOMING APPLICANTS ONLY:
PLEASE ACKNOWLEDGE AND SIGN THE FOLLOWING DISCLOSURE TO YOUR APPLICATION FOR
INSURANCE:
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.)
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