Carter & Company, L.L.P.


 

Oil and Gas Questionnaire

If you would like a representative of Carter and Company to contact you regarding Oil and Gas related insurance coverage, please fill in the form below.  If you would like a quote, scroll down to the In Home Business Questionnaire, fill it out in its entirety and submit it to us.  Either way, we will get back to you as soon as possible.

Information Request Form

Select the items that apply, and then let us know how to contact you.

Send product literature
Send company literature
Have a salesperson contact me

Name
Title
Company
Address
E-mail
Phone

 

Carter & Company, L.L.P.

wpe1A.gif (7518 bytes)
Oil & Gas Questionnaire
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: 
Address:
City:  State: Zip:
Phone Number:     Fax Number:  
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:
General Liability Coverage:

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
Other

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

Annual Payroll:      Est.

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

Loss History - Past Five Years:

Is Insured A Lease Operator or Contractor?
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:
How Many Non-Operating Wells? 0-15% 15.1-50% Over 50% 
Total NOWT's  States Located  ?
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

/

  /

Oil / Gas Contractor's Section
If "drilling, workover or service contractor", specify the following:
No. of rigs Type of Rigs
Maximum depth of drilling/workover Areas of operation
Oil/Gas still erection Yes No  If  Yes, specify

Specialty Contractors
Installation or removal of casing Yes No Well Shooting Yes No
Swabbing Yes No Erection or dismantling of derricks Yes No
Acidizing Yes No Perforating of casing Yes No
Pipeline Construction Over 4" Diameter Yes No Well logging w/ radioactive materials Yes No
Fracturing Yes No Well logging w/o radioactive materials Yes No
Specialty tool operation Yes No Cementing Yes No

 

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.