Influencers Insurance Application (Referral)

Name*
First Last
Email*
Phone*
Website (if any)
Address*
Street Address Address Line 2 City State ZIP Code

Are you an Individual Influencer or Agency?*

Social Media Handles*

Platform	Profile URL	Followers

Click + to add multiple and provide follower count

Date of Birth*
Month
Day
Year
Annual Revenue*
Revenue from advertising on social media only.
Requested Insurance Limit*
Agency Name*
Annual Revenue*
Requested Insurance Limit*

Risk Management Procedures
Please confirm the following:
Do you have a single view rate exceeding 1 million on a post you published on social media to date (we understand future posts may exceed 1 million views and/or go viral).*
- Yes
- No
Please review following statements and answer yes or no below
- You do not write, post or publish anything investigative or exposé.
- You do not write, post or publish any religious, political or satirical content.
- You do not own or host a social media network, website or platform that is primarily for others to post or publish their own content (we understand that you use social media platforms).
- You are aware you cannot use content (such as images or music) that you did not create yourself without obtaining a licenses from the owner.
- You always ensure to comply with the regulations and/or guidelines of each social network provider in relation to paid-for endorsements, maintaining transparency when your content is promoting a brand (eg: using #Ad on promotional Instagram posts).
- You may be involved in the promotion of tangible products, but not in their design, distribution, re-branding, re-packaging or sales.
- You do not promote or endorse alcohol, medications, surgical procedures, vitamins or supplements.
- You agree that you will remove anything that is the subject of a complaint within 48 hours of the complaint being received.
- You not expect that a failure of any of your products or services could result in any loss of life, injury to a person, destruction or damage to physical property.
- I confirm the above statements are true and correct.
Please confirm yes or no to the above statements*
- Yes
- No
If no, please provide details*
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Influencer Insurance Application

Step 1 of 3 - Basic Info

Risk Management Procedures