Oil and Gas Lease Operators / NOWI Questionnaire

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.)

Oil & Gas Lease Operator / Non Operating
Working Interests 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!

Oil and Gas Questionnaire

Named Insured:

Address:

City: State: Zip:

Phone Number: Fax Number:

Contact Name:

Email Address: (Required)

*Social Security # or *FEIN
*Required by insurance companies in order to quote

Please Check Which Coverages You Would Like Us To Quote On:

Quote General Liability Coverage?: Yes No

Limits Required

General Aggregate:

Each Occurrence:

Excess or Umbrella Liability Limit: $1,000,000 Other

Control of Well/Operator's Extra Expense

Oil Lease Property

Workers' Compensation

Professional (For Consultants, Engineers & Geologists

Other

Please list present carrier(s) and your renewal/expiration date(s):

Annual Payroll: Est.

Number of Years In Business: If new operations, outline principal's experience below:

Loss History - Past Five Years:

Describe Any Other Operations:

Oil Lease Operator's Section

Does Insured Have Any Interest In, or Connection To, Any Off Lease Pipelines?

Yes No If so, describe:

Does Insured Have Any Interest In Gas Processing or Sweetning Plant? Yes No

Are any "Over The Hole" Operations Performed By The Insured: Yes No

If So What Are They?

Area or Radius and State(s) of Operations:

Is Any Lease Inside City Limits or Developed Areas or Railroad Right of Way?

If Yes Please Indicate Below:

Does Insured Have Any Operations On or Near Water, i.e.; Lakes, Swamps, Rivers, Creeks, Oceans, Bays, Bayou, or Bog? Yes No If Yes, Please Indicate Below:

Well Schedule

Depth of Operated Wells:	Producing	Producing	Disposal	Plugged	To Be Drilled	Shut-In / T. Aban	Injection
(Operated Wells Only)	(O/S City Limits)	(I/S City Limits)			(O/S City / I/S City)
(a) 0-2000 ft.					/	/
(b) 2001-5000 ft.					/	/
(c) 5001-10,000 ft.					/	/
(d) 10,001 - 15,000 ft.					/	/
(e) 15,001 or Over					/	/

Approximately how many contracts do you have requiring you to name another as additional insured?

Approximately how many contracts do you have requiring waiver of subrogation?

Approximately how many contracts do you have that require a 30 day notice of cancellation?

Do you have all your subcontractors sign a Master Service Agreement including an indemnity clause, additional insured & waiver of subrogation in your favor? Yes No
**Please send us a copy of your standard Master Service Agreement. We have a standard agreement that you are welcome to print and use. Click here to access it. You will need Adobe Acrobat to open this document.

Any off-lease pipeline interest as Operator Non-Operator

Non Operating Working Interest Section

How many non-operating wells are there? 0 - 15% 15.1 - 50%50% Plus Total NOWI's

In what states are these wells located?

Any off-lease pipeline interest as Operator Non-Operator

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