Carter & Company, L.L.P. 

 

 

 

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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! 		 
 1. Named Insured:  Contact Name:
 2. Address: 
 3. City:  State: Zip:
 4. Phone Number:    Fax Number:  
 5. Email Address:
 (Required)
 6. Date Firm Established:
 7. Applicant is: Individual   Partnership   Joint Venture   Corporation
 8. Does firm have: Other subsidiaries?       A parent company?      Other related entities?
  If yes, please explain:
 9. Is there an interchange of employees between companies? No   Yes
  If yes, please describe:
10. List all active "key personnel" including titles and designations.
 
11. Projected Total Gross Payroll:     Gross Manufacturers & Contractors Payroll:
  % Payroll on land;     % Payroll over water (including marshes, bays, inland waters and offshore).
12. Gross Payroll last 12 months:
13. a. Projected Total Revenues:     % Land;     % Over Water
  b. Actual Receipts For: Past 3 Years: 20 $     20 $     20 $    
14. Check any operation or service you currently or, in the future, may perform:
    Standard vertical oil or gas drilling or well completion consulting services.
  Directional/Horizontal oil or gas drilling or well completion services as percentages of receipts: %
  Oil or Gas lease production or well site consulting, inspection, testing or analysis.
  Oil or Gas environmental or pollutant cleanup, testing or other related services.
  Oil or Gas services involving any of the following:
        Re-entry Tools
        Mud
        Chemicals		     Blowout Preventors
    Equipment Sales
    Fishing Tools		     Safety Analysis or loss control service of any kind
    Specialty in-hole well services
    Refineries or Plants
    Equipment Rental
15. Name any professional designations you or your employees have:
 
16. Do you, your employees, or hired subcontractors do any of the following:
    Yes   No   Supervise, manage or control any operations according to verbal or written agreement?
  Yes   No   Supervise, manage or control any any sub-contractor or employees of others?
  Yes   No   Provide written records, analysis, reports, or documentation regarding your operations and/or services to
                             other parties whether or not required by contract written agreement?
  Yes   No   Have any authority or responsibility to anyone regarding any decision making as respects any work or
                             operations performed by you, performed on your behalf or performed by anyone else?
17. Number of actual employees other than yourself:  
18. Does applicant manage, supervise or direct the work of others?   Yes    No
19. If yes, provide details on the type of work supervised or managed:
 
20. If no, provide detail on the type of work performed by applicant:
 
21. Describe 3 major jobs by the applicant in the last year:
 
22. % of work in:   Petro/Chem Plants;   Oilfield;   Industrial Plants;   Over Water;   Environmental
23. Please check below what best described your services:
  As a consultant, I contract with well operators or owners for gathering, researching or analyzing information which may include observing various operations or reviewing reports for recommendations to be made that relate to oil and gas production or exploration. I cannot oversee, instruct, direct, supervise nor have any involvement in any work or operations that occur or may occur at any site.
(IF YOU CHECK THE ABOVE YOU AGREE TO THE FOLLOWING STATEMENT AS A MATERIAL REPRESENTATION FOR ANY COVERAGE TO BE EFFECTED.)
    "As the named insured, the policy coverage terms and conditions and the coverage classification(s) that I request have been fully explained to me by my agent. I completely understand and comprehend that I have no coverage under policy issued if it might be construed, assumed, or deemed by any party that I have any authority, whether implied or not, relating to any operations, work, services, including decisions or judgements made or not made and that might involve or relate to any of my activities covered by the policy."
  As a consultant, I contract with well operators or owners to oversee, instruct, direct, supervise or assist them in work or operations at well or lease sites where oil and gas production or exploration is done. I have authorization obtained from well operators or owners to use my judgment relating to work or activities at the various sites which may include hiring subcontractors and advising personnel regarding their work or activities. I may amend or restrict operations based on my judgment in order to complete any work or site activities. I may have the responsibility to report work progress or lack of progress to well operators or owners.
 
SUBCONTRACTORS
24. Do you hire subcontractors to work for your firm that you pay?   Yes No
25. If so, do you have subcontractor sign your Master Service Agreement and furnish proof that they carry insurance equal to yours?
Yes No
26. What jobs do your subcontractors perform?  
27. Are you responsible for hiring subcontractors on behalf of the operator - not counting subcontractors the operator has previously identified to be called in by you to work the job?   Yes No
28. Do you have a formal safety program?   Yes   No
29. Provide the following details on the General Liability coverage for the last 3 years:

Company Limits Ded/Sir Policy Period

      Premium
1.
2.
3.

30. Provide a five year General Liability loss and expense history (include any claim, suit, or notice that may give rise to a loss):

DOL Description of Occurence or Claim

  

Amount Paid

  

Amount Reserve Status

31. Identify over water exposure (if any):     Click if: None

 
    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?   Yes   No
If yes, number:   Description:

32.
General Liability Insurance Limit Requested:  $,000,000/Occurance,     $,000,000/Aggretage
33.
Excess Liability Insurance Limit Requested:  $,000,000/Occurance,     $,000,000/Aggretage
34.
Professional Liability Insurance Limit Requested:  $,000,000/Occurance,     $,000,000/Aggretage

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!
 

 

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