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Package Choice™ QUOTATION REQUEST
Complete the form with confidence: Hill & Usher does not sell or otherwise transfer any of its database information to other entities for the purposes of marketing to you.

This form will be the only one you will need to complete. To save you time and effort, we have included all the information needed for a policy application. No application will be submitted or bound with the insurance carrier until you have accepted our quotation.

A legible copy of your equipment list is required before we can offer a firm proposal.  Before you begin, you may wish to have available the current insurance policy covering the building and property.

 IMPORTANT INFROMATION REGARDING THE USE OF YOUR INSURANCE/CREDIT SCORE:
By submitting this request for a quotation, you hereby permit the agency, its employees, owners, and affiliated insurers (HILL & USHER, LLC) to use data contained within your "insurance credit score" as the basis for determining your eligibility for our products where permitted by law.  You understand that an unacceptable "insurance credit score" as deemed by our insurance carrier(s) may result in your ineligibility for coverage.  You agree to hold HILL & USHER, LLC harmless from fault or liability in the event that your "insurance score" is unacceptable to the carrier(s), even if the information contained therein proves inaccurate in any way.
Due to privacy concerns and the proprietary nature of "insurance scores," HILL & USHER, LLC will not know the details of your "insurance score."  In compliance with the Fair Credit Reporting Act http://www.ftc.gov/os/statutes/fcra.htm, you have the right to request information about your "insurance score" or to dispute in writing the results of an unfavorable "insurance score."  Upon request, HILL & USHER, LLC will furnish you with contact information for the relevant credit rating bureau.  Your "insurance credit score" is a combination of your business or personal credit history, loss history, and other factors that may reasonably predict the likelihood of future claims.

If you have Questions/Problems with this form please email the webmaster or call our office at (866) 977-4725 between 8AM and 5PM Monday through Friday, Arizona time.

 

Tell us about Yourself...  
First Name
Middle Initial
Last Name
Title
Email Address
Email Address Confirm
First Name or Nickname
(salutation for email messages)

Business Website Address
Are you the final decision-maker concerning insurance coverage for your Company? Yes No

Tell Us About your Business...

Complete Legal Name
of Primary Insured Individual or Entity
Persons With Ownership Interest
 List All Owners of the Business

Registered Trade Name
(DBA, Studio Name, etc.)

Legal Structure
(select one)

If Other Please Explain


Physical Location of Your Business
1st Address Line
City
County
State
(Select One)
State Specific Coverage Issues
Zip Code
(+4 optional)		 -
Do you operate your photography business from any other physical location? Yes No
Do you routinely store equipment or property at any other physical location? Yes No


Mailing Address
(if different from physical location above)
Street Address
City
County
State
(Select One)
State Specific Coverage Issues
Zip Code
(+4 optional)		 -


Business Telephone/Fax
(numbers only-no punctuation)
Area Code & Number
Ext
Fax

Business Operations & Experience
Years in Business
(under your current business entity)
Photography Experience
(total number of years in photography)
Videography Experience
(total number of years in videography)
Film Production Experience
(total number of years in film production)
Wedding & Portrait Photographer Yes No
Other Photography Work Performed
(in addition to wedding & portrait)

Property Valuation &
Please provide the total amount (in whole US dollars) required to COMPLETELY REPLACE each type of property listed below (as if having suffered a total loss of that property today). These figures should represent what would be required to replace the property at current costs. Since some items increase (and others decrease) in price and/or value over time, these amounts may significantly higher or lower than the original cost to purchase the item.

-- CONSIDER THESE VALUES CAREFULLY --
They will be the basis for the limits of coverage under your policy.

Please enter amounts in whole US dollars as numbers only, without punctuation.
EXAMPLE: $10000 (CORRECT) $10,000.00 (INCORRECT)

Cameras & Photographic Equipment
(do not include pc's, peripherals, software etc.)


Note: an accurate quotation requires an itemized listing of your photo equipment. For your convenience, we placed a link in the confirmation email you will receive after submitting of this form.
Maximum value of rented or leased photo equipment at any given time.

Office/studio contents & furnishings (do not include pc's, peripherals, software etc.)

"Tenants improvements and betterments".
(permanent fixtures, cabinetry, appliances, or wall coverings installed in a rented premises at your expense)
Photographic Portfolios
Framed Samples
Annual Sales of Reprints
(of archival stock photographs)

Computer Equipment
(hardware, software, & peripherals)

Your Studio Premises
Residential Locations
Do you work from a residence Yes No
Total Area of Residence
(in square feet)
Area Used for Studio/Office
(in square feet)
Your Studio Premises
Commercial Locations 
Do you own a commercial building which houses your studio? Yes No
If yes, what is the current replacement value of the structure?
Total Area of Commercial Building
(in square feet)
Total Area of YourStudio/Business
(in square feet)
Your Studio Premises
Commercial and Residential Locations 
Type of Construction Used Erecting The Premises Structure

If you are unsure which of the following best describes the type of building construction, please consult the current insurance policy for a description of the type of construction. Construction documents, drawings, appraisals, or ownership documents may also help.Go Back to the Top of the Form.     
Frame Exterior walls of wood, brick veneer, stone veneer, wood ironclad, stucco on wood.
Joisted Masonry Exterior walls of masonry material (adobe, brick, concrete, gypsum block, hollow concrete block, stone, title, or similar materials), with combustible floor and roof.
Noncombustible Exterior walls, floor, and supports made of metal, asbestos, gypsum, or other noncombustible materials.
Masonry Noncombustible Same as joisted masonry except that the floors and roof are of metal or other noncombustible materials.
Modified Fire Resistive Exterior walls, floors and roof of masonry or fire-resistive material with a fire resistance rating of at least 1 hour, but less than 2 hours.
Fire Resistive Exterior walls, floors and roof of masonry or fire-resistive materials with a fire-resistance rating of at least 2 hours.
.

Other, please explain

Year building was constructed

If building is 25 years or older, how many years ago were the following updated Wiring Plumbing Roofing HVAC
Construction Quality
Do you lease parts of your building to other businesses Yes No
If yes, please describe all types of other businesses in your building or at the property address (Example: Greeting Card Store, Fast Food Restaurant)
Burglar Alarm system

Yes No

Brand name of alarm

Air Conditioned Area
Number of Elevators (If any)
Fire Sprinkler System Yes No
Fire / Burglar Protections
(hold CTRL key to select multiple items)
Frequency of Bank Deposits Daily  Weekly  As necessary
Do you Travel outside of US/Canada for Business Yes No
Is your primary motor vehicle equipped with an alarm? Yes No
Do you or any employees leave Photo equipment or other valuable property unattended in your motor vehicle? Yes No
Value of Un-Attended Equipment


Other Coverage-Related Information
Desired Liability Limits
(per occurrence)		 $1000000  $2000000  Other
Annual gross sales
Total Annual Payroll
(not including owner(s))
Workers Compensation Insurance provided for all employees
(as required by law)		 Yes No
Total Number of Staff photographers
(employees)
Number of Other Employees
Total Number of Contracted Photographers
(non-employee/independent contractors)
Require Contractors to Carry Liability & Property Insurance? Yes No
Require Independent Contractors to Carry Workers Compensation Yes No
Do employees/others drive personal vehicles on your behalf Yes No
Number of Certificates of Insurance
(in a typical year-estimated)
Percentage of total business derived from website or interet this year


Additional Underwriting Information
(incomplete or inaccurate information will delay your quote or disqualify you for coverage.)

Current Policy Expiration Date (MM/DD/YYYY)


Current Insurance Carrier
Current Annual Premium

Total dollar value of claims (all types) during the last five years

Number of claims in excess of $500 during last five years

Please briefly describe each claim
(Include Dates & Amounts Paid)

Since the occurrence of claims, what changes in operations or safeguards have been instituted to protect from future loss

Additional Coverage Requests

Requested Policy Effective Date: (MM/DD/YYYY)
(after your acceptance of our quotation and carrier approval of your application)


How did you first come to learn about Package Choice™"

You may make multiple selections by holding down the control key on your keyboard while clicking on desired selections. To undo a selection(s), hold down the control key on your keyboard while clicking or double clicking on undesired selections.

If you found us via a search engine,
what terms did you enter?

Other Comments/questions


By submitting this request, you attest to the accuracy and completeness of the information provided. You understand that no coverage is in force until a policy of insurance is approved and issued on your behalf. Hill & Usher will not be held responsible for coverages not available, coverages not requested by you, or limits not sufficient at the time of this submission.

               

Go Back to the Top of the Form.