Carter & Company, L.L.P. 

 

 

 

(If not in Texas, please click here to view a list of states in which we currently have non-resident licenses.  If your state is not listed then we would not currently have a market for you.)

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Oil & Gas Consultants Quote
For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY! 		 
Named Insured:  Contact Name:
Address: 
City:  State: Zip:
Phone Number:     Fax Number:  
Email Address: (Required)
*Social Security # or *FEIN 
*Required by insurance companies in order to quote
Date Firm Established  
Applicant is:    Individual  Partnership   Joint Venture   Corporation
Does firm have other subsidiaries?        A parent company?      Other related entities?
If yes, please explain
Is there an interchange of employees between companies? No   Yes   If yes, please describe:
List all active "key personnel" including titles and designations.
Projected Total Gross Payroll Gross Manufacturers & Contractors Payroll
% Payroll on land; % Payroll over water (including marshes, bays, inland waters and offshore).
Gross M & C Payroll last 12 months
Projected Total Revenues:               % Land; % Over Water
Description of Operations
Does applicant manage, supervise or direct the work of others?  Yes   No
If yes, provide details on the type of work supervised or managed:

If no, provide detail on the type of work performed by applicant:
Describe 3 major jobs by the applicant in the last year:
% of work in: Petro/Chem Plants;Oilfield; Industrial Plants;Over Water;Environmental
Is applicant responsible for hiring subcontractors? Yes   No  If yes:
Describe the type of work subcontracted: 
Describe the extent of your supervision of these subcontractors:
Do you require these subcontractors to provide certificates on insurance evidencing the following insurance coverage is currently in force:

Type of Insurance

Y/N

            Minimum Limits Required
Workers Compensation Y  N
Commercial General Liability Y  N
Maritime Employers Liability Y   N
Do you require your firm to be named as additional insured on the subcontractors general liability? Y  N
Do you obtain a waiver of subrogation on subcontractors workers compensation policy?   Y  N
Type of indemnity agreement signed with subcontractors?
Is applicant held harmless by subcontractor? Y  N
Is there a mutual hold harmless? Y  N
Other (Describe)
If applicant is not responsible for hiring subcontractors, who is?
Describe applicants extent of supervision of these subcontractors.
Type of indemnity agreement signed with applicant's client. 
Whose favor does harmless run? 
Does firm ever enter into a contract wherein the sole negligence of the indemnity is assumed? Y  N
Do you have a formal safety program? Y   N
Provide the following details on the General Liability coverage for the last 3 years:
Company Limits Ded/Sir Policy Period

       Premium
1.
2.
3.
Provide a five year General Liability loss and expense history (include any clain, suit, or notice that may give rise to a loss):

DOL Description of Occurence or Claim

Amount Paid

Amount Reserve Status

Identify over water exposure:

                                                                Expected

           Expiring
USL&H Payroll (Gross)                  $

$
JONES ACT Payroll (Gross)          $

$
Number of Men Exposed:Any One Time Any One Place
Number of Men Exposed Annually?
Number of Marsh, Bay, and/or Inland Water Jobs During the Past 12 months:  %
Fixed Platform: %   Other: %
Number of offshore jobs during the past 12 months: %     Fixed Platform: %   Other:%
Does the insured own, lease, and/or operate watercraft?  Y  N
If yes, number:   Description:
Limit of coverage desired: 

 

Thank you for your time in submitting this Oil & Gas Insurance quote form. One of our representatives will respond to your submission as soon as possible!
 

 

Send mail to info@cartercompany.com with questions or comments about this web site.