Northumbrian Water Insurance Questionnaire - This Document must be completed by your Broker or Insurer

Insurance Questionnaire
IMPORTANT NOTE
All sections should be completed by the INSURER or INSURANCE BROKER.
If a section is NOT relevant, as cover is not held, please mark it as NOT APPLICABLE (N/A).
Insured: /

Point Productions Ltd

Address: / Maxwell Building, Room 41, Elstree Studios, Shenley Rd, Borehamwood, Herts, WD6 1JG
Contact Name: / Ben Piltz
BUSINESS DESCRIPTION(as defined on the insurance policy)
TBC

Production Information

Production Title
‘Grimsby’
Northumbrian Water / Essex & Suffolk Water site(s) to be used
Hanningfield Water Treatment Works / Start and End Dates
Start: 27.05.14
End: 07.06.14 / Maximum no. of people on site
200
Will moving vehicles be filmed
NO / Will you work at height
Yes / Will you be working on water
NO
List all sub-contractor companies providing services on site (catering, make-up, wardrobe, driving,
Andy Dixon Facilities – Facilities and technical vehicles
Red Chutney Ltd – Catering
Film & Television Scenery Construction Ltd – Construction
TBC – Camera & Lights
Details of any hazardous activities or stunts, including any fire sequences and use of explosives. List any chemicals which will be brought onto site.
No stunts or SFX

Public / Product Liability – NWL should be included as a joint insured

a) / FULL Name of Insurer? / Chartis
b) / Policy Number? / 80-0273951
c) / Expiry Date? / 11/01/2014
d) / Limit of Liability / £ 1M GBP / In any one occurrence
Is this limit reduced for any specific risks? / No
If “Yes”, please provide details:
Excess / Deductible? / Do not disclose
e) / Is Product Liability included? / YES
f) / Does the Policy cover:
Indemnity to Principal? / YES
Liability in respect of loss or damage to property of NWL / YES
Contractual Liability? / YES
Are NWL included as joint insured / No – Yes as an Additional Insured or Interested Party
g) / Detail exclusions that would apply to any work being performed i.e. height and depth exclusions?
Participation in Stunts or Hazardous Activities including but not limited to involving animals, underwater shooting, motorcycles, special vehicles, aircraft, water craft, railway locomotives or rolling stock, fire sequences, explosives?
N/A
(If there is insufficient space available please attach full details)

Employers Liability

a) / FULL Name of Insurer? / TBC
b) / Policy Number? / TBC
c) / Expiry Date? / TBC
d) / Limit of Liability? / £ TBC / In any one occurrence / in aggregate
(Delete as applicable)
Is this limit reduced for any specific risks? / TBCYES / No (delete as applicable)
If “Yes”, please provide details:
TBC
Excess / Deductible? / TBCNOT APPLICABLE to Employers Liability
e) / Does the Policy cover:
Indemnity to Principal? / TBCYES / No (delete as applicable)
Contractual Liability? / TBCYES / No (delete as applicable)
f) / Detail exclusions that would apply to any work being performed i.e. height and depth exclusions?
Participation in Stunts or Hazardous Activities including but not limited to involving animals, underwater shooting, motorcycles, special vehicles, aircraft, water craft, railway locomotives or rolling stock, fire sequences, explosives ?
N/A
(If there is insufficient space available please attach full details)
Motor Insurance – If Vehicles are to be used
a) / FULL Name of Insurer? / N/A
b) / Policy Number? / N/A
c) / Expiry Date? / N/A

Third Party Property Damage Limit

/

N/A

Excess

/

N/A

f) / Please confirm cover includes if applicable:
Precision Stunt Driving / N/A
Racing / N/A
In the event that further clarification is required, with regards to the extent of your insurances, please detail below the contact name(s) and number(s) of your authorised representative(s).
Primary Contact:
(Please print) / Michael Lombardi / Contact Tel. No. / (646) 572-3923
Secondary Contact:
(Please print) / Dawn Luehrs / Contact Tel. No. / (310) 244-4230
Declarationby Insurer / Broker
Weconfirm that all information provided within this form is,to the best of our knowledge,accurate and that the current policy premium has been paid in full to the Insurers concerned.

Signed:-

/ TBC / Print Name:- / TBC

Position in Company:-

/ TBC / Contact Tel. No:- / TBC
Email:- / TBC / Date:-

Company Name and Address:-

/ Lockton Companies, Inc.
1185 Avenue of the Americas, Ste. 2010
New York, NY 10036 / Insurers / Brokers stamp
TBC
FSA Reg. No.
IMPORTANT NOTE
THIS DECLARATION MUST BE COMPLETED BY AN INSURANCE COMPANY OR BROKER AND ACCOMPANIED BY AN INSURANCE SUMMARY ON THE INSURERS’ OR BROKERS’ LETTER HEADED PAPER. We do not release to third parties.
IMPORTANT Declaration
We confirm that should our Insurance cover be cancelled or is subject to a change, asa result of a claim or other event, we will inform Northumbrian Water Ltd

Signed:-

/ TBC / Print Name:- / TBC

Position in Company:-

/ TBC / Contact Tel. No:- / TBC
Email:- / TBC / Date:-TBC