Fillable KINSALE Lease Operator Non Operator Supplemental

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KINSALE Lease Operator Non Operator Supplemental

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Page 1 of 6
LEASE OPERATOR/NON-OPERATOR SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1. Applicant:
2. Years in business: Years of experience:
3. Web site:
4. Have you operated or are you operating under a different business name now or at any time Yes No
over the past 10 years? Provide details:
5. State/area of operation:
Current Year 1
st
2nd Prior Year Prior Year 3
rd
4 Prior Year
th
Prior Year
Annual Gross Receipts
Employee Payroll
Cost of Subcontracted Work
# of employees
1. Are you an operator of record owning working interest in wells and utilizing a Yes No
contract operator to manage lease operation?
2. Are you an operator of record owning working interest in the wells and Yes No
managing the lease operations for their co-owners of the working interest?
3. Are you an operator of record not owning working interest in the wells but who utilizes Yes No
a contract operator to manage lease operations?
4. Are you a lease operator by contract who does not have a working interest Yes No
in the wells?
5. Are you a promoter selling drilling prospects to operators in exchange for a Yes No
carried interest in the wells?
6. Are you an investor owning a non-operating working interest? Yes No
APPLICANT’S INFORMATION
OPERATIONS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
7. How are drilling and/or work over operations contracted?
Daywork: IADC AP I Other (please attach a copy)
Footage: IADC AP I Other (please attach a copy)
Turnkey: IADC AP I Other (please attach a copy)
Other:
On Land/Dry Wells for OPERATORS:
Well Type: Number of Wells
Well Depth 7,500 Ft or Under Well Depth 7,500 Ft or Over
Producing
Shut-In
Salt Water
Disposal
To Be Drilled
TOTAL:
Offshore/Wet Wells for OPERATORS:
Well Type: Number of Wells
Well Depth 7,500 Ft or Over Well Depth 7,500 Ft or Over
Producing
Shut-In
Salt Water
Disposal
To Be Drilled
TOTAL:
8. Are any wells within city or town limits? Yes No
9. Are any wells within 1000 feet of an occupied structure? Yes No
10. Are all well sites fenced in (including pump jacks, tank batteries, separators, etc)? Yes No
11. Are there any livestock on the lease area? Yes No
12. Are any wells in a railroad right-of-way? Yes No
Page 3 of 6
13. Are there any hydrogen sulfide wells? Yes No
14. Do you supply house gas? Yes No
If yes, how many taps?
If yes, is there a hold-harmless agreement in your favor for all taps? Yes No
If yes, is there a pressure regulator for each tap? Yes No
If yes, is there a written requirement for the homeowner to odorize the gas? Yes No
15. Do you operate any gathering systems that are primarily servicing 3
rd
If yes, how many gathering systems?
party wells? Yes No
If yes, how many miles of gathering systems?
16. Do you own or operate or a working interest in any gas sweetening plants, gas processing Yes No
plants or gasoline recovery plants?
If yes, please provide details:
On Land/Dry Wells for NON-OPERATORS:
Well Type: Number of Wells
Well Depth 7,500 Ft or Over Well Depth 7,500 Ft or Over
Producing
Shut-In
Salt Water Disposal
To Be Drilled
TOTAL:
Offshore/Wet Wells for NON-OPERATORS:
Well Type: Number of Wells
Well Depth 7,500 Ft or Over Well Depth 7,500 Ft or Over
Producing
Shut-In
Salt Water Disposal
To Be Drilled
TOTAL:
17. How many miles of pipeline do you operate?
Page 4 of 6
18. How many miles of pipeline do you non-operate?
Diameter of the pipeline?
Age of the pipeline?
19. Does the pipeline supply end users? Yes No
If yes, please provide details:
20. What are the surrounding 3
rd
party exposures of the pipeline (populated areas, etc)?
21. Is the pipeline crossing any rivers, creeks or roads? Yes No
If yes, please explain:
22. What percent of work do you subcontract to others? %
23. Do you usually use the same subcontractors? Yes No
24. Are subcontractors always insured? Yes No
25. What general liability limits do you require your subs to carry?
26. Are you named as an additional insured on all subcontractors’ policies?
27. Do you have a written contract with your subcontractors? If yes, provide a copy. Yes No
28. Do you obtain certificates of insurance from all subcontractors? Yes No
29. How long do you retain those certificates?
Describe your last 5 projects Dollar Value
1.
2.
3.
4.
5.
Describe your 5 largest projects Dollar Value
1.
2.
3.
4.
5.
30. During the past five years, has any insurer ever canceled or non—renewed similar insurance to Yes No
any applicant or has your insurance been canceled for non—payment of premium by any insurance
or finance company?
If yes, please explain:________________________________________________________________________________
Page 5 of 6
31. Has any lawsuit ever been filed, or any claim otherwise been made against your company or any Yes No
partnership or joint venture of which you have been a member or your company’s predecessors
in business, or against any person, company or entities on whose behalf your company has performed
operations or assumed liability? For the purpose of this application only, a claim means a receipt of a
demand for money, service or arbitration.
If yes, please explain including the name(s) of the person, company or entity and the name(s) and locations(s) of the
projects where such operations were performed: (attach separate sheet if necessary)
32. Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages Yes No
or accidents (including but not limited to: allegations of faulty or defective workmanship, product
failure, construction dispute, property damage or construction worker injury) at a location or project
where your company has performed operations that a reasonably prudent person might expect to
give rise to a claim or lawsuit whether valid or not which might directly or indirectly involve the company?
If yes, please explain including the names(s) and location(s) of the projects where such operations were
Performed. (Attach a separate sheet if necessary.)
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 person 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.
NOTICE 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 company 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 Colorado Division of Insurance 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 insurer may deny insurance 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 information is guilty 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 who 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 LOUISIANA 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 crime and may be subject to fines and confinement in prison.
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 information 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 crime and may be subject to civil fines and criminal penalties.
Page 6 of 6
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 statement of claim 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 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 knowing that he/she is facilitating 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 insurer, 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 company, or other person, files an
application for insurance or statement of a claim 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 and subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 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 company. 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, misstate 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 withdrawn
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 hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE Lease Operator Non Operator Supplemental

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Completed 2 July 2020

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