HomeMy WebLinkAboutInsurance Example
SAMPLE CERTIFICATE OF INSURANCE AND ADDITIONAL
INSURED POLICY ENDORSEMENT FOR FILMING
A certificate of insurance and endorsement is required for any filming that takes place on City public property or
private property that requires a Filming Registration Form. The City reserves the right to require additional
insurance levels based on specific activities or equipment included in the production.
Certificate of Liability Insurance, Additional Insured Policy Endorsement and Proof of Worker’s Compensation must be submitted
with the Filming Registration Form.
INSURANCE AGENT NAME
INSURANCE AGEND ADDRESS
INSURANCE COMPANY NAME(S )
INSURED NAME
INSURED ADDRESS
Coverage
• Commercial General
Liability
• Auto Liability
• Proof of Workers
Compensation
Minimum Limits
For Filming or Still
Photography:
• $1,000,000 per
occurrence
• $2,000,000 aggregate
Additional Insured
City of Palm Desert , its
officers, employees and
agents named as
additionally insured.
• If a policy contains
“blanket” additional
insured, then the
certificate must note:
“City of Palm Desert is
additional insured by
blanket endorsement”.
• If policy has no blanket
endorsement (see
following page for sample).
Insurance Company
• Must be licensed to do
business in California.
POLICY
NUMBER
POLICY
NUMBER
POLICY
NUMBER
CURRENT
POLICY PERIOD
CURRENT
POLICY PERIOD
CURRENT
POLICY PERIOD
$1,000,000
$2,000,000
$1,000,000
$1,000,000
$1,000,000
The City of Palm Desert, its officers, officials, employees and agents as additional ly insured.
The City of Palm Des ert
73510 Fred Waring D rive
Palm Desert , CA 92260
$1,000,000 $2,000,000
SAMPLE CERTIFICATE OF INSURANCE AND
ADDITIONAL INSURED POLICY ENDORSEMENT FOR FILMING
Certificate of Liability Insurance, Additional Insured Policy Endorsement and Proof of Worker’s Compensation must be submitted
with the Filming Registration Form.
Additional Insured
• City of Palm Desert , its officers, officials, employees and agents
named as additional insured
City of Palm Desert, its officers, officials, employees , and
agents shall be included as additional insured .