Production Title
Production Company Entity
Production Type
Feature Film
Television Series
Streaming Series
Commercial Advertisement
Music Video
Documentary
Live Broadcast
Other
Primary Contact Name
Primary Contact Email
Primary Contact Phone
Insurance Policy No.
Insurance Carrier
Primary Shoot Location Name / Venue
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GPS Coordinates
Property Owner Consent (Upload Site Access Agreement)
Start Date & Time
End Date & Time
Location Environment (Site parameters)
Stunt Coordinator Name
Guild / Board Certification No.
Phone Number
Special Effects (SFX) Supervisor Name
Pyrotechnic / Explosives License No.
Phone Number
Lead Safety Officer Name
First Aid / Paramedic Cert Level
Choice A
Choice B
EMT-Basic
Paramedic
Registered Nurse
Wilderness First Responder
Personnel & Participant Counts
Category | Estimated Count | On-Site Safety Briefing Scheduled? | |
|---|---|---|---|
Stunt Performers / Doubles | |||
SFX Crew & Technicians | |||
Cast Members Involved | |||
Background / Extras |
Select all high-risk physical elements involved in this operation:
High Falls
Precision Driving & Vehicle Crashes
Wirework / Rigging / Harnesses (Mechanical winches, counterweight systems)
Fire-on-Performer (Full or Partial Burn)
Combat / Weapons Work (Blades, martial arts, blunt props)
Water Operations (Scuba, submerged vehicles, swift water)
Aviation / Aerial (Helicopters, drones, ultralights)
Required Upload: Attach detailed Stunt Action Plan & Storyboards
Class 1 Pyrotechnics / Explosives (Squibs, flash powder, detonations)
Open Flame / Propane Burners (Fire bars, flame throwers)
Atmospheric Effects (Smoke, haze, fog, glycol, oil-based, artificial snow)
Pneumatic / Mechanical Rigs (Ratchets, air cannons, vehicle rolls)
Breakaway Materials (Sugar glass, resin glass, balsa wood, breakaway walls)
Blank Firing Firearms
Substance / Material | Classification | Max Quantity On-Site | Storage Method | |
|---|---|---|---|---|
Required Upload: Attach Safety Data Sheets (SDS) for all chemical and pyrotechnic agents
Fire Suppression Plan
Number of Class A/B/C Fire Extinguishers on set
Dedicated Fire Watch Personnel assigned?
Fire Department Standby Requested / Required?
Medical & Evacuation Plan
Dedicated On-Site Ambulance/Medic?
Nearest Trauma Center Hospital Name
Transit Time to Hospital (minutes)
Primary Evacuation Route Description
Perimeter Security & Public Safety
Perimeter Lock-off Distance (ft)
Off-Duty Police / Traffic Control Officers Hired?
Notification Issued to Surrounding Residents/Businesses?
Yes
No
N/A
Please ensure the following files are uploaded before submitting:
Item | Upload File | |
|---|---|---|
Job Safety Analysis (JSA) / Risk Assessment Matrix | ||
Site Layout & Safety Perimeter Map | ||
Armourer / Pyrotechnician Licenses | ||
Local Fire Marshal Pre-Approval Notice (if applicable) |
I hereby certify under penalty of perjury that all information provided in this application is true, correct, and complete to the best of my knowledge. I agree to abide by all municipal, state/provincial, and federal safety regulations, union safety bulletins, and local authority mandates governing stunt and special effects operations.
Applicant Name
Title / Role
Applicant Signature