Insurance Cert Request Form

Insurance Cert Request Form - University of Central Florida...

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Unformatted text preview: University of Central Florida Film Department 4000 Central Florida Blvd. Communications Building ยท Room 121 Orlando, FL 32816-3120 (407) 823-4285 โ€ข [email protected] Request Form for Certificate of Insurance Instructions: Fill this form out completely and EMAIL it to Lisa Cook. Please allow ample time to process the request โ€“ at least 2 business days. Once I have approved your request, I email our agent the form and she emails back a certificate. I forward the certificate to you via email. It is your responsibility to get copies of the certificates to the correct recipients on your project. THIS FORM MUST BE EMAILED TO ME. NO HANDWRITTEN REQUEST FORMS WILL BE ACCEPTED. Please provide the info for the Person/company asking for proof of insurance: Company โ€‚โ€‚โ€‚โ€‚โ€‚ Mr./Ms. โ€‚โ€‚โ€‚โ€‚โ€‚ Address โ€‚โ€‚โ€‚โ€‚โ€‚ City, State, Zip โ€‚โ€‚โ€‚โ€‚โ€‚ Phone number โ€‚โ€‚โ€‚โ€‚โ€‚ Fax number โ€‚โ€‚โ€‚โ€‚โ€‚ Website address โ€‚โ€‚โ€‚โ€‚โ€‚ Email of contact person โ€‚โ€‚โ€‚โ€‚โ€‚ Director of film: โ€‚โ€‚โ€‚โ€‚โ€‚ Name of Project: โ€‚โ€‚โ€‚โ€‚โ€‚ Phone number of Student Director: โ€‚โ€‚โ€‚โ€‚โ€‚ Email of Student Director: โ€‚โ€‚โ€‚โ€‚โ€‚ Name of Student Producer: โ€‚โ€‚โ€‚โ€‚โ€‚ Phone number of Student Producer: โ€‚โ€‚โ€‚โ€‚โ€‚ What class is this film for?: โ€‚โ€‚โ€‚โ€‚โ€‚ Who is the faculty member teaching this class? โ€‚โ€‚โ€‚โ€‚โ€‚ Location(s): โ€‚โ€‚โ€‚โ€‚โ€‚ Date(s) of shoot(s): โ€‚โ€‚โ€‚โ€‚โ€‚ Hours of shoot (list hours for each day you will be shooting, including setยญup and wrap time): โ€‚โ€‚โ€‚โ€‚โ€‚ Describe nature of shoot โ€“ any stunts, effects, minors, animals, guns, pyro? โ€‚โ€‚โ€‚โ€‚โ€‚ How many TOTAL cast and crew expected?: โ€‚โ€‚โ€‚โ€‚โ€‚ How many TOTAL cars, trucks, vehicles expected?: โ€‚โ€‚โ€‚โ€‚โ€‚ ...
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