Accident on Set | Form 01-ASP Application

"*" indicates required fields

1Producer Information

2Risk Assessment

If a required field (indicated by *) does not apply to you, please enter N/A. You will not be able to proceed without doing so.

Terms & Conditons*

I agree, I acknowledge that my coverage will only begin once my application has been approved and payment has been received. Please note that same-day application coverage is not available. If you require urgent coverage, please contact AFBS directly.

Application – Alberta Stunt Performers Only

Individuals participating in an extreme sport or excessive risk activity, are excluded from coverage.

Producer Information

Production Company*

Production Title*

Producer(s)*

Permanent Address*

Permanent Address (Suite, Number, and Street Name)* City* Province* Postal Code*

Canadian Address (if different from “Permanent Address”)

Canadian Address (if different from "Permanent Address" - Suite, Number, and Street Name) City Province Postal Code

Contact Name*

Contact Telephone*

Contact Email*

Risk Assessment: (required)

A copy of the stunt coordinator’s resume*

Drop files here or

Max. file size: 1,000 MB.

The name and ACTRA # of performers who will be involved in stunt action*

The coordinator’s description of planned stunts or related material, such as diagrams, photos or storyboards showing any stunt action, especially any stunt gags that may not be standard*

Drop files here or

Max. file size: 1,000 MB.

Are activities planned that could be considered an extreme sport or excessive risk?*

Yes

Extreme Sports and Excessive Risk Activities excluded from coverage

Extreme sports and excessive risk activities are specialized risks and excluded from coverage under the Accident on Set insurance program. Extreme sports and excessive risk activities include, but are not limited to, activities such as ice climbing, mountain climbing, rock-face climbing, heli-skiing, big-wave surfing, high-level cliff diving, mountain back-country skiing/snowboarding/snowmobiling, big-mountain skiing, other sports involving X Games, sports involving Big Air, and BASE jumping/ski-BASE jumping, as well as activities such as high wire and certain aerobatics. The Accident on Set insurance program reserves the right to deny liability for any claims that may result. Production may wish to contact their film insurance broker or general liability insurer in order to ensure appropriate coverage is in place for these types of risk.

I/We hereby request enrolment for the named Production in the AFBS Accident on Set Insurance Program, as described in the provisions of the Master Insurance Policy for the period outlined below, subject to extension by mutual agreement.

The acceptance of this Application is at the discretion of AFBS and subject to the issuance of a Certificate of Insurance for the named Production. I/We understand that acquiring Accident on Set insurance does not change nor waive any liability to register with a workers’ compensation program, if required.

I/We understand that acceptance of this Application is conditional on the undersigned accepting all the terms and conditions of the Policy, which includes all provisions, and/or endorsements attached to said Policy and the requirement that the Production maintains general liability insurance coverage.

Instructions

Insurance Coverage Start Date (see instructions below)*

Prime Set Location(s) City/Province*

Insurance Coverage End Date (see instructions below)*

2nd Unit Set Location(s) City/Province

Insurance Coverage Start Date – Remember to include rehearsals, read-throughs, camera tests and fitting days when determining the Insurance Coverage Start Date.

Insurance Coverage End Date – Remember to include any ADR when determining the Insurance Coverage End Date.

Premium Remittance to AFBS

Via Cast and Crew

Via Entertainment Partners (EP)

Pay AFBS directly (please append a copy of your stunt list to this application)

Other payroll service*

I accept*

By selecting the “I accept” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I accept” using any device, means, or action, I consent and agree to the legally binding terms and conditions contained in this document and confirm that I am applying for AOS coverage as described herein on behalf of the named production. I further agree that my signature on this document is as valid as if I signed the document in writing, and confirm that I am authorized by the named production to enter into this Agreement.

Name of Authorized Signatory*

Title*

Date Signed*

Application – Alberta Stunt Performers Only

Producer Information

Risk Assessment: (required)

Instructions

Email

Phone

Toronto Address

Vancouver Address