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KINSALE EG Professional App - EG_Professional_App

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Page1of4

OILANDGASPROFESSIONALLIABILITYAPPLICATION 

1. Legalnameofthebusinesswhoistheprimaryapplicantandwillbethefirstnamedinsuredlistedonthepolicy:

_________________________________________________________________________________________________

2. Pleaselistallotherbusiness/dbanamesforwhichyouareseekingcoverageunderthispolicy:  



Corporation  Individual Partnership Municipality ForProfit JointVenture

Other:

3. Pleaselistanynamesofotherentitiesthatyouownormanageorthatyoudobusinessunderandforwhichno

coverageisbeingappliedfor.



4. Primarylocationaddress:

5. Datebusinessoriginallyestablished:__________________________

6. Totalnumberofbranches?  Listalladdressesforadditionalbranches:

_______

7. Whatisyourweb‐siteaddress?www.  __________________________________________________

8. Hasthenameorownershipoftheentitychangedorhasanyotherbusinessbeenpurchased, Yes No 

mergedorconsolidatedwiththeentitywithinthelast5years?

9. Doesanyentityownorcontrolyourbusinessordoesyourbusinessownorcontrolanyentity? Yes

No 

10. Duringthepastfiveyears,hasyournamebeenchangedorhasanyotherbusinesspurchased, Yes

No 

mergedorconsolidatedwithyou?

Forquestions9‐11,pleasefullyexplainany“yes”response,includingthenames,dates,andrevenueimpactinvolved:





11. Hasanyprofessionalstaffmemberoremployeebeenthesubjectofdisciplinaryactionbyauthorityasaresultoftheir

professionalconductoractivity?Ifyes,providedetails.Yes

 No 

___________________________________________________________________________________________________

__________________________________________________________________________________________________

12. Pleaselistallassociationsandindustrygroupsofwhichyouareamember:



 ___



Describeyouroperations:





Pleaseprovideyourestimatedrevenueinthesecategories:



ENERGY(OILANDGAS)CONSULTINGORENGINEERING



Petroleumgeologyandengineeringservicesandinvestigations 

Surveying 

APPLICANT’SINFORMATION

GENERALINFORMATION

KinsaleInsuranceCompany

P.O.Box17008

Richmond,VA23226

(804)289‐1300

www.kinsaleins.com

Page2of5



Explorationincludingsubsurfacemapping 

Seismicservices

Welldevelopmentanddrillplanning

Reserveestimationsorsimulations

Safetymanagement

Projectsupervision

Owner’srepresentative

Facilityorpipelineengineeringandinspection 

Terminalorstoragefacilityengineering

Formationevaluation

Completionengineering

Frackingdesign

Other:Describe:  





 CurrentYear 1

PriorYear 2ndPriorYear 3

PriorYear 4

PriorYear

AnnualGrossReceipts 

EmployeePayroll 

CostofSubcontractedWork 

#ofemployees 



Doesanysingleclientprovideover25%ofgrossreceipts? Yes

No 

If“Yes,”pleaseprovidethenameoftheclient,thedollarvalueofthiswork,andadescriptionoftheworkperformed:







Pleaseestimatethepercentageofyourworkthatcomesfromthefollowingindustriesorsources:



Commercial _____%

Industrial _____%

Utilities _____%

Oil/Gas  _____%



Environmental _____%

Contractors  _____%

Government  _____%

Other(describe) _____%



Whatpercentageofyourworkisdoneunderyourcontract______%oryourclientscontract________% 

nocontract______%

DoesYOURco

ntractcontainalimitationofl

iabilityclause? Yes

No 

Dothecontractsyousigncontainamutualindemnity(knockforknock)clause? Yes

No 

Doyousubcontractanyofyourprofessionalservicestootherprofessionals? Yes

No 

Ifyouanswered“Yes”,doyouuseawrittencontract? Yes

No 

Doyourequiresubcontractorstocarryinsurancecoveragethatisequaltoorbroaderthanyours? Yes

No 

Doyourequireyoursubcontractstonameyouasanadditionalinsuredontheirpolicies? Yes

No 

Howdoyouselectyoursubcontractors?_______________________________________________________________

________________________________________________________________________________________________

Doyouexercisecontrolofyoursubcontractorsordirecttheiractivities? Yes

No 

Doyoucontrolormanageworksites,projectsorfieldwork? Yes

No 

Whatpercentageofyourconsultingoperationsareperformedinthefield?______________%

Doyouhavewrittenhealthandsafetyplan? Yes

No 

Doyouhaveapeerreviewprocessforallwrittenreports,assessmentsandopinions? Yes

No 

Isyourworkapprovedbywrittenacceptance? Yes

No 

Page3of5



Doyouhaveanyoffshoreorwetoperations? Yes

No 

 Ifyes,whatpercentageofyouroperationsareoffshoreorwet?___________%

 Ifyes,pleaseprovidedetailsonthetypesofworkdone:

 Ifyes,howareyoutransportedoffshore?

Whatisthepercentageofnon‐oilfieldconsultingoperations?____________%

Areallconsultantsdegreedengineers? Yes

No 

Howmanyemployeesareconsultants?____________

Whatpercentageofyourconsultingoperationsareperformedinthefield?____________%

Areyouresponsibleforhiringand/orfiringothersubcontractors? Yes

No 

Doyouexercisecontroloverothersubcontractor’sactivitiesordirecttheiractivitiesatall? Yes

No 

Doyoucontrolormanageworksites,projectsorworkinthefield? Yes

No 

Doyouofferormakerecommendationsorsuggestionstoclients? Yes

No 



Providedetailsofthefive(5)largestprojectsundertakenduringthelast12months.Ifastart‐up,pleaseinsteadprovidea

projectionofthetypeandsizeofprojectscontemplated:



NameofClient DescriptionofServices GrossReceipts LengthofContract

 



Pleaseprovidethetotalnumberof:Officers/Partners  ProfessionalStaff OtherStaff  



KeyStaff ProfessionalLicensesHeld YearsofExperience LengthofEmployment

  



Provideyourentity’srecentinsurancehistorybelow.



 

InsuranceCompany

LimitsPer

Claim/Aggregate

PolicyPeriod

(Month/Day/Year) AnnualPremium

CurrentYear 

PreviousYear1 

PreviousYear2 

PreviousYear3 

INSURANCEANDLOSSHISTORY

Page4of5



Ifyouarecurrentlyinsuredforerrors&omissionscoverage,whatisyourpolicy’sretroactive/prioractsdate?

(month/day/year)_____/_____/_______Ifthereisnoretroactivedate,pleasecheckhere.



Areyoubeingcanceledornon‐renewedbyyourcurrentprofessionalliabilitycarrier?

Yes No 

Ifyes,pleaseexplainwhy:      

   



Requestedlimits:

$1M/$2M $2M/$2M (other)   



Re

questeddeductible: $2,500 $5,000 $10,000 $25,000 Other$ 



Inthelastfive(5)years,haveanyclaimsbeenmadeagainstthepersonorentityapplyingforinsurance,oranyofyourpast

orpresentmembers,partners,officers,directors,employees,oranypredecessorsinbusiness?

Yes No  

If“yes”,pleaseprovidedetailsonaseparatepage.



Areyou,oranyofyourpartners,officers,directors,oremployees,awareofanycircumstances,acts,errors,omissions,or

anyallegationsorcontentionsofanyincidentwhichmayresultinaclaim? Yes

No 



If“yes”,pleaseprovidedetailsonaseparatepage.



Haveyou,oranyofyourpartners,officers,directors,oremployeesbeenthesubjectofanycomplaintorsubjecttoany

disciplinaryactionbyanystatelicensingagencyorotherregulatorybodyduringthepastfive(5)years? Yes

No 



If“yes”,pleaseprovideanexplanationofthecircumstancesandpenaltyinvolved.Ifavailable,pleaseprovideacopyof

thecomplaint,yourresponse,andacopyoftheregulatorybody’sdecision.



FRAUDWARNING



NOTICETOALABAMA,ALASKA, ARIZONA, ARKANSAS, CALIFORNIA,CONNECTICUT,DELAWARE, GEORGIA, IDAHO,ILLINOIS,INDIANA,IOWA, KANSAS,

MARYLAND,MASSACHUSETTS,MICHIGAN,MINNESOTA,MISSISSIPPI,MISSOURI,MONTANA,NEBRASKA,NEVADA,NEWHAMPSHIRE ,NORTHCAROLINA,

NORTHDAKOTA,OREGON,RHODEISLAND,SOUTHCAROLINA,SOUTH DAKOTA,TEXAS,UTAH,VERMONT,WASHINGTON,WESTVIRGINIA,WISCONSIN,

AND WYOMING APPLICANTS:In some states, any pe

rso

n who knowingly, and with intent to defraud any insurance company or other person,files an

application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information

concerninganyfactmaterialthereto,maycommitafraudulentinsuranceactwhichisacrimeinmanystates.



NOTI

CETOCOLORADOAPPLICANTS:Itisunlawfultoknowinglyprovidefalse,incompleteormisleadingfactsorinformationtoaninsurancecompanyfor

thepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialofinsuranceandcivildamages.Any

insuranceco

mpanyoragentofan

insurancecompany who knowingly provides false,incompleteormisleadingfactsor information toapolicyholder or

claimantforthepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimingwithregardtoasettlementorawardpayableforinsurance

proceedsshallbereportedtotheCol

oradoDivisionofIn

surancewithintheDepartmentofRegulatoryAgencies.



NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:  WARNING:It is a crime to provide false or misleading information to an insurer for the purpose of

defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insur

er may deny insura

nce benefits if false

informationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.



NOTICETOFLORIDAAPPLICANTS:Anypersonwhoknowinglyandwithintenttoinjure,defraudordeceiveanyinsurancecompanyfilesastatementofclaim

containinganyfalse,incompleteormisleadinginfor

mationisguil

tyofafelonyofthethirddegree.



NOTICETOHAWAIIAPPLICANTS:Foryourprotection,Hawaiilawrequiresyoutobeinformedthatpresentingafraudulentclaimforpaymentofalossor

benefitisacrimepunishablebyfinesorimprisonment,orboth.



NOTICETOKENTUCKYAPPLICANTS: Anypersonwh

oknowinglyand

withintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor

insurancecontaininganymateriallyfalseinformationorconceals,forthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommits

afraudulentinsuranceact,whichisacrime.



NOTICETOLOU

ISIANAAPPLICANTS:Anyperson

whoknowinglypres entsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresents

falseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.



Page5of5



NOTICETOMAINEAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeof

defraudingthecompany.Penaltiesmayincludeimprisonment,fines,ordenialofinsurancebenefits.



NOTICETONEWJERSEYAPPLICANTS:Anypersonwhoincludesanyfalseormisleadinginfor

mationonan

applicationforaninsurancepolicyissubjectto

criminalandcivilpenalties.



NOTICETONEWMEXICOAPPLICANTS:Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresents

falseinformationinanapplicationforinsuranceisguiltyofacri

meandmaybesubje

cttocivilfinesandcriminalpenalties.



NOTICETONEWYORKAPPLICANTS:Anypersonwhoknowinglyandwithintent todefraudaninsurancecompanyorotherpersonfilesanapplicationfor

insuranceorstate ment ofclaim containing  anymateriallyfalse information,or conceals,forthepu

rposeof misleading, information

concerning any fact

materialthereto,commitsafraudulentinsuranceact,whichisacrimeandshallalsobesubjecttoacivilpenaltynottoexceed$5,000andthestatedvalue

oftheclaimforeachsuchviolation.



NOTICETOOHIOAPPLICANTS:Anypersonwho,withintenttodefraudorknowi

ngthathe/sheisfac

ilitatingafraudagainstaninsurer,submitsanapplication

orfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.



NOTICETOOKLAHOMAAPPLICANTS:WARNING:Any personwhoknowingly,andwithintenttoinjure,defraudordeceive anyi

nsurer,makesaanyclaim

for

theproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.



NOTICETOPENNSYLVANIAAPPLICANTS:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecomp any,orotherperson,filesanapplication

forinsuranceorstatementofacl

aimcontaininganym

ateriallyfalseinformationorconcealsforthepurposeofmisleading,informationconcerninganyfact

materialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectsthepersontocriminalandcivilpenalties.



NOTICETOTENNESSEEAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incom

pleteormisleadinginform

ationto aninsurancecompanyforthepurpose 

ofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.



NOTICETOVIRGINIAAPPLICANTS:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurpose

ofdefraudingthecompan

y.Penaltiesinclude

imprisonment,finesanddenialofinsurancebenefits.



TheApplicantacknowledgesthattheanswersprovidedhereinarebasedonareasonableinquiryand/orinvestigation.TheApplicantwarrantsthatthe

abovestatementsandparticularstogetherwithanyattachedorappendeddocumentsaretrueandcompleteanddonotmisrepresent,miss

tate

oromit

anymaterialfacts.

TheApplicantagreestonotifyusofanymaterialchangesintheanswerstothequestionsonthisquestionnairewhichmayarisepriortotheeffective

dateofanypolicyissuedpursuanttothisquestionnaireandtheApplicantunderstandsthatanyoutstandingquotationsmaybemodifiedorwithdr

awn

baseduponsuchchangesatoursolediscretion.

Completion ofthisformdoes not bind coverage. Applicant’sacceptanceofthe company’s quotationis required priorto binding coverage andpolicy

issuance.



All written statements and materials furnished to the company in conjunction with this application are here

by incorporated by reference in

to this

applicationandmadeapartofthisapplication.



Applicant:   Title: 

 (MustbesignedbyaPrincipal,Partner,orOfficeroftheFirm)



Applicant’sSignature:   Date:   



Agent/BrokerName:     

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Completed 2 July 2020

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