Production Start Date Production End Date
DD MM YYYY DD MM YYYY
Name of Authorized Signatory (please print) Title
Prime Set Location(s) City/Province 2nd Unit Set Location(s) City/Province
Premium Remittance to AFBS
Via Entertainment Partners (EP)
Pay AFBS directly
(please append a copy of your cast list to this application)
Other payroll service
Authorized Signature (electronic signature not allowed) Date Signed
DD MM YYYY
Accident on Set Insurance Program Fax: (416) 967-4744 / Toll Free Fax: 1-888-804-8929
Actra Fraternal Benefit Society E-mail Address: admin@accidentonset.com
I/We hereby request enrolment for the named Production in the Actra Fraternal Benefit Society (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 the AFBS. 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.
I/We understand that both the calculation and payment of premium due are the responsibility of the Production
company and the method of payment to AFBS is indicated below.
PLEASE PRINT AND FAX OR E-MAIL TO:
Underwritten by:
Actra Fraternal Benefit Society: 1000 Yonge Street, Toronto, Ontario M4W 2K2
Telephone: (416) 967-6600 / Toll Free: 1-800-387-8897 Fax: (416) 967-4744 / Toll Free Fax: 1-888-804-8929
E-mail: admin@accidentonset.com Website: www.accidentonset.com
Low Budget/Deferral Productions (Total Production budget under $100,000)
No Yes
If Yes, are there stunt/risk performances? No Yes
(If there are stunt/risk performances, append a copy of the Risk Assessment Form)
I
NSURANCE COVERAGE FOR PERFORMERS
Application
for Accident on Set Insurance Program
FORM 01-A
Production Company
Production Title Producer(s)
Permanent Address Street Name, Suite and Number City Province Postal Code
Canadian Address (if different from “permanent address”) Street Name, Suite and Number City Province Postal Code
Contact Name Contact Telephone
( ) -
Contact E-mail
PRODUCER INFORMATION: (please print)
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