Media Insurance Claim

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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

• Date of Loss: July 15, 2054

• 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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