October 2022

The Risk Management Plan Form

Students must complete and e-mail this form to their advisor or instructor via email for approval before the start of any film project. Should the advisor/instructor not approve the RMP, they will send the RMP back to the student with their comments for correction. Once the advisor/instructor approves the RMP, they will email a copy to Risk Management. RMPs must be on file with Risk Management at least 14 business days in advance of the first shooting day for final insurance evaluation and consideration. Refer to the Student Handbook for a guide on how to complete the Risk Management Plan.

The Office of Risk Management relies, in good faith, upon the information provided in this checklist. If any student intentionally conceals or misrepresents any fact material to the risk associated with the film project, Office of Risk Management reserves the right to void the student film insurance policy and students will be responsible for payment of claims in the event of a loss.

Please note this form was created using Repeating Section Content Controls. Users can repeat sections of this form by toggling the “+” button on the right-hand side of the selected section.

Section 1 – Contact Information
Name	Phone	Email
Director	insert text here	insert text here	insert text here
Producer	insert text here	insert text here	insert text here
Project Coordinator	insert text here	insert text here	insert text here
Other	insert text here	insert text here	insert text here

Section 2 – RTF Course Information
Project Title (Name of Film)	insert text here
Course Title	Number
Radio, Television, and Film Course	insert text here	insert text here
Name	E-mail	Phone Number
Professor/Instructor	insert text here	insert text here	insert text here

Section 3 – Brief description of film, risks, and protection measures
Project Description
insert text here
Project Risks and Protection Measures
Risk Description	Protection Measures
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Section 4 – Project Location (complete one for each location) If you require a certificate of insurance, all fields must be completed.
Name of Location	insert text here
Address Street 1	insert text here
Address Street 2	insert text here
City, State, and Postal Code	insert text here
Contact/owner’s Name	insert text here
Phone Number	insert text here
Start Date and Time	Click or tap to enter a date.
End Date and Time	Click or tap to enter a date.
Description of Activities	insert text here
Certificate of Insurance Required?	☐ TRUE	☐ FALSE
FOR OFFICE USE ONLY	insert text here
Name of Location	insert text here
Address Street 1	insert text here
Address Street 2	insert text here
City, State, and Postal Code	insert text here
Contact/owner’s Name	insert text here
Phone Number	insert text here
Start Date and Time	Click or tap to enter a date.
End Date and Time	Click or tap to enter a date.
Description of Activities	insert text here
Certificate of Insurance Required?	☐ TRUE	☐ FALSE
FOR OFFICE USE ONLY	insert text here

Section 5 – Location Exposures Complete for each location
Location Exposures and Protection Measures
Risk Description	Protection Measures
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Section 6 – Transit Exposures Complete for all transportation
Transit Exposures and Protection Measures
Risk Description	Protection Measures
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Section 7 – Set-up Exposures Complete for all set-ups
Set-up Exposures and Protection Measures
Risk Description	Protection Measures
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Section 8 –Scene Exposures Complete for all scenes
Scene Exposures and Protection Measures
Risk Description	Protection Measures
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Section 9 –Tear Down Exposures
Tear Down Exposures and Protection Measures
Risk Description	Protection Measures
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Section 10 – Non-Northwestern Loaned or Rented Equipment (complete each field for each vendor) *If a certificate of insurance is required, you must include a university chart string for payment
Vendor Name	insert text here
Address Street 1	insert text here
Address Street 2	insert text here
City, State, and Postal Code	insert text here
Contact/Owner’s Name	insert text here
E-mail Address	insert text here
Phone Number	insert text here
Loaned/Rented?	insert text here
Start Date and Time	Click or tap to enter a date.
End Date and Time	Click or tap to enter a date.
Person Responsible	insert text here
Itemized List of Equipment	Equipment	Replacement Value
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*Certificate of Insurance Required?	☐ YES	☐ NO
Fund	Dept ID	Project ID
Chart string	insert text here	insert text here	insert text here
FOR OFFICE USE ONLY – REF	insert text here
FOR OFFICE USE ONLY – Premium	insert text here

Section 11 –Non-Northwestern Equipment Exposures
Non-Northwestern Equipment Exposures and Protection Measures
Risk Description	Protection Measures
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Section 12 – Northwestern Owned Equipment
Equipment/Property	Replacement Costs	Responsible Person	Pick-up Date	Return Date
insert text here	$insert text here	insert text here	Click or tap to enter a date.	Click or tap to enter a date.
insert text here	$insert text here	insert text here	Click or tap to enter a date.	Click or tap to enter a date.
insert text here	$insert text here	insert text here	Click or tap to enter a date.	Click or tap to enter a date.
insert text here	$insert text here	insert text here	Click or tap to enter a date.	Click or tap to enter a date.
insert text here	$insert text here	insert text here	Click or tap to enter a date.	Click or tap to enter a date.

Section 13 – Northwestern Owned Equipment Exposures
Tear Down Exposures and Protection Measures
Risk Description	Protection Measures
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Section 14 – Transportation Information List all means of transportation that will be used throughout the production process. Describe what and where the students will use the vehicles for and their hours of operation. Students must request special permission to use Northwestern vehicles and rentals between 9:00PM and 5:00AM.
Date/Time	To	From	Transportation Method
Click or tap to enter a date.	insert text here	insert text here	Choose an item.
Click or tap to enter a date.	insert text here	insert text here	Choose an item.
Click or tap to enter a date.	insert text here	insert text here	Choose an item.
Click or tap to enter a date.	insert text here	insert text here	Choose an item.
Click or tap to enter a date.	insert text here	insert text here	Choose an item.

Section 15 – University Vehicles
Name	insert text here
Driver’s License No.	insert text here
Rental Agreement No.	insert text here
Name	insert text here
Driver’s License No.	insert text here
Rental Agreement No.	insert text here

Section 16 – Privately Owned Vehicles Please note that Northwestern will not provide primary automobile insurance coverage to students using their personal vehicles. Students who choose to use 3rd party rentals, outside of the university’s rental program, must obtain the appropriate insurance coverages.
Vehicle (Year, Make, Model)	insert text here
Owner	insert text here
Insurance Company	insert text here
Policy Number	insert text here
Vehicle (Year, Make, Model)	insert text here
Owner	insert text here
Insurance Company	insert text here
Policy Number	insert text here

Film Safety Disclaimer Checklist

Producers should ensure, as far as reasonably practical, that persons working with and for them are not exposed to health and safety risks. It is important to always identify your risks, how likely and severe the outcome(s) may be and take appropriate action to prevent them from occurring. This checklist will give you a general idea of what to check for prior to filming.

Check all that apply
☐	All members on set have been shown and understand emergency procedures
☐	All members on set have been made aware of the COVID-19 safety precautions
☐	Fire equipment (sprinklers/extinguishers) and exit doors must be accessible at all times
☐	Walkways and aisle ways are to be kept clear - cables in walkways and traffic areas will be covered
☐	Wear appropriate clothing and any required personal protective equipment (i.e. long sleeves or safety glasses)
☐	All members on set have been trained in personal fall protection and will use fall protection when necessary
☐	Tools, ladders, and other equipment on set will be inspected prior to each use to check for defects
☐	Tools, ladders, and other equipment will be properly selected and used as intended by the manufacturer
☐	Perform team lifts or use material handling equipment when lifting or moving heavy and awkward objects
☐	Understand location-specific hazards (i.e. extreme temperatures, plants, critters, etc.)
☐	All drone usage adheres to Northwestern's Unmanned Aircraft Policy

Coverage Exclusions
Northwestern does not provide insurance coverage for the following:
Open fires, fireworks, smoking, and pyrotechnics
Operating farm/construction machinery, watercrafts, aircrafts, snowmobiles, etc.
Activity involving two-wheeled, three-wheeled, or off-road vehicles
Use of real firearms, alcohol, or illegal substances
Throwing or dropping anything from a vehicle
Bungee jumping, skydiving, or rock climbing
Activity on scenes open to the public
Films requiring workers' compensation coverage
Live animals

Student(s) must obtain their own insurance for these activities or get insurance coverage from the owner or contractor hired. Insurance coverage from the owner or contractor hired must include Northwestern University as an additional insured and be for at least $3 million per occurrence coverage. Even with outside insurance Northwestern has the right to deny the activity and students that violate this policy will no longer be eligible for insurance from Northwestern

Signature Page

By signing this document, I certify I have received and read the Student Film Insurance Policy and Film Safety Disclaimer Checklist. I understand the deductible provisions set forth in the Student Film Insurance policy and acknowledge that all members of any assigned group of students for a production assignment share equal responsibility for loss, theft, or damage to equipment. I hereby voluntarily and willingly assume all risk and dangers associated with my participation in this activity. These risks could result in damage to property, personal, and/or bodily injury. I have been advised my personal medical insurance is the primary medical coverage payment and that Northwestern University will not provide workers compensation coverage in the event of injury.

In consideration of my participation in this film project, I hereby waive all claims of action against Northwestern University, its officers, directors, employees, students, and agents, all of which are collectively referred to as the “University”, arising out of my participation in the film project. I hereby release, hold harmless, and discharge the University from any and all claims that may occur as a result of my participation in this film project.

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Name	Name
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Role	Role
Signature	Signature
Date	Date

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Name	Name
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Role	Role
Signature	Signature
Date	Date

Faculty Approval

I have reviewed and approve the film’s script and RMP, and I confirm that it is part of the curriculum requirement for the academic course.

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Name
Signature
Date

Additional Space for Notes/Comments

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