AFFIDAVIT OF ELIGIBILITY

COVERFLY FEE WAIVER PROGRAM

I am a resident of COUNTRY: ________________ STATE: ________________________

COUNTY: _______________________
MY FULL LEGAL NAME IS: __________________________________
My date of birth is (month) ___________ (day) ______________ (year)
My email address is _____________________________________.

I am submitting this Affidavit of Eligibility to Red Ampersand, Inc (d.b.a. Coverfly) located in the
State of California (“Sponsor”), so as to confirm my eligibility in the Fee Waiver Program
(“Program”). I was 25 years of age or older at time of entry.

I affirm and represent that I have complied with all the rules and regulations of the program. I state that I
have not committed any fraud or deception in entering the program or in claiming any grant, waiver, or
status. I further state that I am not an employee, contractor, director or officer of Red Ampersand and
each of their respective parents, subsidiaries and affiliated companies, distributors, Web design,
advertising, fulfillment, insurance agencies, judging and program agencies involved in the administration,
development, fulfillment and execution of this program (collectively, “program Parties”). Red Ampersand,
each of their respective subsidiaries, affiliates, shareholders, officers, directors, agents, representatives
and employees, or of any other entity stated in the Official Rules whose employees, officers and directors
are not eligible to enter the program, nor am I a member of the family as defined in the Official Rules or
living in the same household of any such employee, officer or director.

I understand that all federal, state and local taxes and charges on the grant I may win and any other
expenses and costs related to my participation in the Promotion and the acceptance and use of the grant
which are not specified in the Official Rules will be my sole responsibility.

I hereby waive, release, forever discharge and agree to hold harmless Red Ampersand and all of
their respective parents, subsidiaries and affiliated companies, advertising and promotion
agencies, web masters/suppliers, and all of their respective officers, directors, employees,
representatives, agents, contractors, judges, readers, advertisers and sponsors from and against
any and all claims, demands, losses, causes of action and liabilities of any nature whatsoever,
which the undersigned may now have or which may arise, or hereafter be entitled to asset, against
each or any of them, for any matter, cause or thing, including, but not limited to any death, loss,
injury or damage to person or property, or loss of enjoyment, or other harm or loss of any nature
whatsoever, whether direct, compensatory, incidental or consequential, caused or contributed in
whole or in part, directly or indirectly, to my acceptance, use or misuse of the status of “Winner”
in this Promotion, or my participation in this program or any program related activity, including
but not limited to the airing of the commercial Submission.

Red Ampersand or any other partner, employee or agent associated with this program claims no
ownership nor first right of option to any original screenplay submitted to this program. All
ownership and rights to the scripts submitted to this program remains with the original rights
holders until and unless other agreements are made. I agree to release and indemnify and hold
harmless the Red Ampersand entity, Sponsor and the program Parties from any and all claims
that any commercial, advertising, presentation, Web content or any other material subsequently
produced, presented, and/or prepared by or on behalf of Sponsor infringes on the rights of my
work as contained in any Submission.

The awarding of the grant program will be conditional on this affadavit being properly and fully completed
and received by Sponsor no later than​ ​today’s date. ​Sponsor reserves the right to require me to
submit to a confidential background check to confirm eligibility and help ensure that the use of
any such person in advertising or publicity for the program will not bring Sponsor into public
disrepute, contempt, scandal or ridicule or reflect unfavorably on the program as determined by
Sponsor in its sole discretion.

Upon request of Sponsor, I shall execute and deliver such additional instrument of assignment, as may be
solely deemed by Sponsor, reasonably necessary to establish the ownership of record of the right, title
and interest in and to the Submission and of the copyrights transferred and “Moral Rights of Authors”
waived under these Official Rules. Should Sponsor fail to request the said assignment as stated, that
shall not be deemed a waiver of Sponsor’s rights and Sponsor may at a later time request the
assignment.

I FURTHER UNDERSTAND AND AGREE THAT ALL RIGHTS UNDER SECTION 1542 OF THE CIVIL
CODE OF CALIFORNIA AND ANY SIMILAR LAW OF ANY STATE OR TERRITORY OF THE UNITED
STATES ARE HEREBY EXPRESSLY WAIVED. SECTION 1542 READS AS FOLLOWS:

1542. CERTAIN CLAIMS NOT AFFECTED BY A GENERAL RELEASE. A GENERAL RELEASE DOES
NOT EXTEND TO CLAIMS WHICH THE CREDITORS DOES NOT KNOW OR SUSPECT TO EXIST IN
HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM MUST HAVE
MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.

I understand that if I make any false statements herein, I will automatically be disqualified. I acknowledge
that I will automatically be disqualified if this Affidavit of Eligibility and Liability/Publicity Release is not
received in the enclosed envelope by the date first stated above. It is understood and agreed that this is a
complete RELEASE AND DISCHARGE of all claims and rights of the undersigned against the
aforementioned parties to be released, and that no action will be taken by or on behalf of the undersigned
with respect of any such rights.

It is further understood and agreed that this Affidavit of Eligibility and Liability/Publicity Release shall be
binding upon the heirs, executors, assigns and administrators of the undersigned or any other party taking
or having taken by or through me.

I HAVE READ, FULLY UNDERSTAND, AND AGREE WITH THE FOREGOING TERMS AND
CONDITIONS.

SIGNATURE(S) REQUIRED

___________________________________ _____________________
Signature of Applicant Date