Media Insurance Claim
I. Policyholder Information
Policyholder Name: | [Your Company Name] |
Contact Person: | [Your Name] |
Policy Number: | M12345678 |
Address: | [Your Company Address] |
Contact Number: | [Your Company Number] |
Email: | [Your Email] |
II. Claimant Information
Claimant Name: | Jane Smith |
Relation to Policyholder: | Producer |
Contact Number: | 321-654-0987 |
Email: | jane.smith@example.com |
III. Description of Loss
Nature of Loss: On July 15, 2054, during the filming of the project "The Great Escape," a critical lighting rig malfunctioned, causing extensive damage to the equipment. Additionally, a key actor was injured, leading to significant production delays.
Location of Incident: Studio 5, Film City Studios, 789 Movie Blvd, Film City, CA 90001
Impact on Production: The incident resulted in the suspension of filming for two weeks. This delay has impacted the project's timeline, leading to additional costs for rescheduling, location rental extensions, and compensations.
IV. Claim Amount
the Item | Description | Amount |
|---|
Equipment Damage | Lighting rig and camera damage | $15,000 |
Production Delays | Cost of rescheduling crew, extended rentals | $25,000 |
Other Costs | Medical expenses for injured actor, additional security | $10,000 |
Total Claim Amount: | $50,000 |
V. Support Documentation
Proof of Loss: Incident report filed with the production company, witness statements, and security footage.
Receipts and Invoices: Invoices for damaged equipment, rental extensions, and medical bills.
Photographs: Attached are images of damaged equipment and set location.
Other Relevant Documents: Medical reports for the injured actor, and contractual agreements for rescheduling.
VI. Declarations and Signatures
I/We hereby declare that the foregoing statements are true to the best of my/our knowledge and belief. I/We agree to provide further information if required.
Policyholder:
[Your Name]
[Date Signed]
Claimant:
Jane Smith
[Date Signed]
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