Multimedia Liability Coverage

APPLICATION for AXIS PRO® WriteInsure™

LIABILITY POLICY

I. GENERAL INFORMATION –

1. Are you an: Individual Non-Profit Organization For-Profit Organization

First Named Insured (Individual or Organization name, including DBAs):

NOTE: First Named Insured is responsible for premium payment, cancellation and changes – refer to specimen policy.

Address Line 1:

Address Line 2:

Address Line 3:

City, State, Zip Code: Telephone Number:

Email:

2. Are you a member of Authors Guild? Yes No

3. Please select your desired policy limit and retention levels, based on your individual needs. Keep in mind that premiums will

increase as coverage limits increase.

Each Loss Limit / Total Limit of Insurance / Retention (Deductible)
$100,000 / $300,000 / $2,500
$250,000 / $250,000 / $2,500
$500,000 / $500,000 / $2,500
$1,000,000 / $1,000,000 / $5,000

II. FREELANCE WRITING QUESTIONS –

PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR INTEREST IN FREELANCE WRITING COVERAGE:

4. Please provide a brief summary of the nature of your freelance writing activities.

5. What is your gross annual revenue derived from all freelance writing activities?

$0-$10,000 $10,001-$50,000 $50,001-$100,000 $100,001-$150,000 Greater than $150,000

6. How long have you been a published freelance writer?

Less than 1 year 1-3 years 4-7 years 8-10 years Greater than 10 years

7. Approximately how many of your articles have been published in the past year in each category listed below?

Technical Writing
General Business
Pharmaceutical/Healthcare
Consumer Complaints
Local Government Activities
Investigative or Exposé
Real Estate Development
All other topics

8. Do you engage in any of the following investigative or newsgathering activities?

A) Hidden recording devices

B) “Ride-alongs” with law enforcement

C) Undercover investigations

D) No

9. Do you have a lawyer to consult with on legal issues relating to your articles? Yes No

10. For your non-fiction articles, do you document sources of information and material facts?

Yes No N/A (I do not write non-fiction.)

11. When using copyrighted content in your articles, do you obtain necessary licenses, permissions or consents to use such material?

Yes No N/A (I do not use copyrighted materials.)

12. Has any actual claim or lawsuit been made against you arising out of your freelance writing activities in the last 10 years?

Yes No

13. Are you aware of any allegation, circumstance or error or omission arising from your freelance writing activities that may reasonably be expected to result in a claim or lawsuit? Yes No

III. BOOK AUTHOR QUESTIONS –

PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR INTEREST IN BOOK AUTHOR COVERAGE:

14. Please provide the title or tentative title of the book you plan to publish within the policy period:

15. Edition Number: First Edition Second Edition Third Edition Fourth Edition Fifth Edition

16. Please provide a brief synopsis of the work you intend to publish:

17. Type of work:

Fiction / Poetry / Children and Young Adult
Religious / Arts and Cinema / Sexuality
Science / Sports / Travel
Health / Autobiography / Biographical Current/Living Subject
Biographical Historical/Deceased Subject / History / Law
Technical/Mechanical / Business/Finance / How-to-do-it
Social Studies/Political Commentary / Investigative Reporting/Exposé / Other Non-fiction

18. Type of distribution: Traditional Publisher Self-Publisher

19. If you distribute via a self-publisher, please specify which type:

Subsidy Publisher Print-on-Demand (POD) or eBook N/A

20. What is the name of your publisher? Enter N/A if self-publisher.

21. Does your publisher have its in-house legal department or any outside legal counsel “vet” or review your work prior to publication?

Yes No

22. Estimated number of copies to be published or downloaded:

Less than 500 500-1,000 1,001-2,000 2,001-5,000 5,001-10,000 More than 10,000

23. What is your estimated gross revenue derived from your publication, including any advances?

$0-$10,000 $10,001-$50,000 $50,001-$100,000 $100,001-$150,000 Over $150,000

24. How many works have you published or self-published before? None 1 2-5 6-9 10+

25. Has any actual claim or lawsuit been made against you arising from your publications in the last 5 years? Yes No

26. Are you aware of any allegation, circumstance, error or omission arising from your publication that may reasonably be expected to

result in a claim or lawsuit? Yes No

27. If you used copyrighted content in your publication, such as photos, artwork, or third-party contributions, have you obtained the

necessary licenses, permissions, or consents to use such material? Yes No N/A (I did not use copyrighted content.)

28. If your publication is non-fiction, have you documented sources of information and material facts?

Yes No N/A (My publication is NOT non-fiction.)

29. Do you have a lawyer to consult with on legal issues in relation to your publication? Yes No

30. If you have entered into a contract with a publisher, are you required to indemnify the publisher from any claims or lawsuits arising

out of your work? Yes No N/A (I don’t have a contract.)

IV. BLOGGING QUESTIONS –

PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR INTEREST IN BLOGGING COVERAGE:

31. Please provide the URL for the blog site that you wish to insure: HTTP://

32. Please provide a brief summary of the nature of your blog site:

33. How long has your blog site existed: Less than a year 1-3 years 4-7 years 8-10 years Greater than 10 years

34. What is your gross annual revenue derived from the blog you wish to insure?

$0-$10,000 $10,001-$50,000 $50,001-$100,000 $100,001-$150,000 Over $150,000

35. Do you engage in any of the following investigative or newsgathering activities: the use of hidden cameras/microphones; “ride-

alongs” with law enforcement; or “undercover investigations”? Yes No

36. Do you collect or store any personally identifiable information about your readers or visitors (e.g. names, addresses, phone

numbers, and/or financial information)? Yes No

37. Does your blog site have other regular contributors (other than general postings or comments by readers or visitors)?

Yes No

38. Protecting copyrights is an important area of the law. Does your blog site allow for the uploading or downloading of previously

published music, video or other material for which you do not own or control the rights? Yes No

39. Are you employed or retained by a specific organization or business to promote its products or services, and/or comment on its

competitors in your blog? Yes No

40. Has any actual claim or lawsuit been made against you arising out of your blogging activities? Yes No

41. Are you aware of any allegation, circumstance or error or omission arising from your blogging activities that may reasonably be

expected to result in a claim or lawsuit? Yes No

42. Does your blog site relate to any of the following:

A) Information on products prior to the release of these products to the general public?
B) Local government activities?
C) Pharmaceutical or healthcare industries?
D) Real estate development activities?
E) Forums for consumer complaints about products or services?
F) No

43. Do you have a lawyer to consult on legal issues relating to your blog site? Yes No

44. Are you currently employed by a media organization as a journalist? Yes No

V. REPRESENTATIONS –

By signing this application, you agree that:

1. The statements and answers furnished to the Company in this application are accurate and complete;

2. The statements and answers furnished to the Company are representations you are making to the Company on behalf of all

persons and entities proposed for coverage;

3. Those representations are a material inducement to the Company to provide insurance;

4. Any policy the Company issues will be issued in reliance upon those representations;

5. You will report to the Company immediately, in writing, any material change to you or your entity’s operations, conditions or

answers provided in this application that occur or are discovered between the date of this application and the effective date of any

policy, if issued; and

6. The Company reserves the right, upon receipt of any such notice, to modify or withdraw any proposal for insurance the Company

has offered.

WARNING
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 MAY BE PUNISHABLE BY FINES AND CONFINEMENT IN PRISON.
Name / Name
(please type or print) / (signature of Authorized Representative)
Title / Date
Agent or Broker:
Address, Zip Code:
Telephone:
Facsimile:
Email address:

NOTICE TO ARKANSAS 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 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 LOUISIANA APPLICANTS:

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 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.

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.

NOTICE TO NEW MEXICO APPLICANTS:

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 NOT 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 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.

SURPLUS LINES NOTICE FOR RHODE ISLAND APPLICANTS:

THIS INSURANCE CONTRACT HAS BEEN PLACED WITH AN INSURER NOT LICENSED TO DO BUSINESS IN THE STATE OF RHODE ISLAND BUT APPROVED AS A SURPLUS LINES INSURER. THE INSURER IS NOT A MEMBER OF THE RHODE ISLAND INSURERS INSOLVENCY FUND. SHOULD THE INSURER BECOME INSOLVENT, THE PROTECTION AND BENEFITS OF THE RHODE ISLAND INSURERS INSOLVENCY FUND ARE NOT AVAILABLE.

SURPLUS LINES NOTICE FOR SOUTH CAROLINA APPLICANTS:

THIS COMPANY HAS BEEN APPROVED BY THE DIRECTOR OR HIS DESIGNEE OF THE SOUTH CAROLINA DEPARTMENT OF INSURANCE TO WRITE BUSINESS IN THIS STATE AS AN ELIGIBLE SURPLUS LINES INSURER, BUT IT IS NOT AFFORDED GUARANTY FUND PROTECTION.

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.

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