1.

Assured: 

(company name)

2.

Assured Address:

(address, city, state, country, postal code)

(phone number)

4

Operator: 

(company name)

5

Operator Address:

(address, city, state, country, postal code)

6.

Well site Contractors:

(drilling, drilling mud, directional driller)

7.

Well Name:

  (Well name on Permit)                   (New well or Redrill)        (If re-entry, any sticking or loss problems)

8.

Well Location:

  (Field Name)                        (Nearest Town)                         (County, State, Country)

9.

Well Information:

Maximum Mud Weight (oil, water or synthetic)       

Attach Schematic or fill out

     @

(Total Vertical Depth)  
 

(Total Measured Depth)
 

 (Horizontal Displacement)

   (Target Formation)
   
  

(Kick-off Point)

(Smallest ID)  

(Maximum Bottom
Hole Temp)

(Maximum Estimated Bottom Hole Pressure)

(Maximum  Angle)

(Developmental  Well or Exploratory)   

(Target Form. Lithology)

(Gas or Oil well,
%HxS, %CO2)

10.

Approximate date tools go below rotary:

11.

Estimate time tools are in use below rotary:

12.

Is operator (this well) insured under a Control of Well Policy?

13.

Is the MWD wireline retrievable?

14.

Will you use a top drive or a conventional rotary rig?

15.

Years in business:

16.

Experience of application supervisors:

17.

What are your past tool losses in this type of application (when, location, reason for lost)?

Quantity 

Description

Serial No.

Value

Opt. 1

Opt. 2

MAXIMUM VALUE OF TOOLS DOWNHOLE AT ANY ONE TIME:

DATE:

Email Address