SAG-AFTRA Health Plan
SAG-Producers Pension Plan | AFTRA Retirement Fund
All Information Must be Completed for Processing
Remit to SAG-AFTRA Health Plan and:
SAG-Producers Pension Plan AFTRA Retirement Fund
Commercials Select one:
Television Audio
Plan Code # Payroll period Report/payment due
Late Penalty: Payments and reports received over 30 days after the due date will be assessed liquidated damages and/or interest.
Total compensation subject to contributions $
Employer’s contribution @ % of compensation $
Liquidated damages if applicable @ % $
Commercial
Infomercial
Signatory employer
Reporting compan
y
Address
T
elephone
Email
If New ID, indicate last reported ID
Advertiser
Signatory
Yes No
Brand/Product Product type
Adv
ertising Agency
Production Compan
y
Ad ID
Commercial title Length in seconds Original session date(s) 1
st
air date
Lift ID/title Length in seconds Cycle dates
Report type:
Session Holding Use Credit (clarify in comments)
Other (specify in comments) Check here if Spanish-language
Signature Name Title Date
Program
Class A Class B
Class C With NY
Dealer
Type A Type B
8-week 6-month
With NY
26 week – Audio
Cable
Made for FM Broadcast
Cable Maximum (3000 units)
If less, enter Total Cable Units:
Foreign
United Kingdom
Japan
Rest of world
Europe
Asia Pacific
Foreign – Audio
Spanish Language
Program
Spot
Total Spot Units:
South/Central-Amer/Mexico
Caribbean
Upfront
Plus
Flex
Digital
Audio Network Program
1 week 4 week 8 week
13 week 26 uses 39 uses
Internet Made-For Move-Over 4-week 8-week 1 year Theatrical/Industrial Exhibition
New Media Made-For Move-Over 4-week 8-week 1 year Other (specify in comments)
WILD SPOT / Audio Regional Network Program 8 week audio 13 week audio
Audio Flex
Mecha nic al Edi ts # of Tags_______________________
Bundles
10 20 30 40 50
4 week
8 week
13 week
6 month
1 year
New York Los Angeles Chicago
List additional cities if necessary:
___________________ ____________________
___________________ ____________________
No. of additional cities: Total spot units:
CLASS A USE DETAIL: List additional uses in Comments or on a separate report.
13 Use Guarantee Applied
In “L/D” Column, mark uses of “included lift” with “L,” mark uses to which discount
applies with “D.” Note any separate Use Number sequence for uses of 10-15-second
version in Comments.
Use # L/D Date Program Use # L/D Date Program Use # L/D Date Program
Comments:
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
U
S
E
T
Y
P
E
Make check payable to: SAG-AFTRA Health Plan Check No.
P.O. Box 54867, Los Angeles CA 90057 Phone (818) 973-4472
(For additional performers see reverse)
1 of 2
Commercials
If you have questions about this form contact the SAG-AFTRA Health Plan at (818) 973-4472 or employercontributions@sagaftraplans.org
For contract rates, visit www.sagaftraplans.org/rates
Digital
Terrestrial
Regional Use____________________
click to sign
signature
click to edit
SAG-AFTRA Health Plan
SAG-Producers Pension Plan | AFTRA Retirement Fund
All Information Must be Completed for Processing
Additional Performers
2 of 2
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
Social Security
Number
Performer’s Name
Last First Initial
Perf Type Camera If Session Report, Indicate:
If upgrade, show amount
already paid for cycle.
Compensation
Multi Service
Contract
ON
OFF
# Of
Commls
Date(s)
worked
Birthdate, if
under age 4
YES
NO
If you have questions about this form contact the SAG-AFTRA Health Plan at (818) 973-4472 or employercontributions@sagaftraplans.org
For contract rates, visit www.sagaftraplans.org/rates
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome