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- OIL & GAS RISK SUPPLEMENTAL APPLICATION Oil (Philadelphia Insurance Companies)

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- OIL & GAS RISK SUPPLEMENTAL APPLICATION
Oil & Gas Contractors and Consultants – GL / CEC / Professional Package
INSTRUCTIONS
• Please answer all questions completely. If any question does not apply, please check “no” or state “N/A”.
• If additional space is required, please provide on separate sheet and reference the section and question number.
• This form must be signed and dated by an Owner, Partner, Director / Officer or Principal of the Applicant.
• This application is to be used in conjunction with a completed E-PAC primary application.
SECTION I – OIL & GAS CONSULTANTS, ROUSTABOUTS & OILFIELD CONTRACTING OPERATIONS
1.
First Named Insured:
2.
Mailing Address:
City:
State:
Zip:
3.
List the states the Applicant works in:
4.
Does the Applicant work offshore or overwater (river, bay, estuary, marsh)?
No
If yes, please provide details:
5.
Specify the number of employees by category including principals:
a.
Administrative Management:
g.
Geologists or Hydro Geologists:
b.
Clerical and Accounting Employees:
h.
Petroleum Engineers:
c.
Draftsmen, Technicians, Inspectors, Surveyors:
i.
Other: (specify)
d.
Field Personnel:
e.
Field Supervisors:
f.
General Engineers other than Petroleum Engineers:
Total number of employees:
6.
Specify the percentage of services for each of the following categories: The total must equal 100%.
a.
Environmental:
%
c.
Oilfield:
%
e.
Petrochemical Plants:
%
b.
Industrial Plants:
%
d.
Over Water:
%
f.
Other:
%
7.
Description of well site consulting services, if applicable:
a.
Oil & Gas Consultants
(Observe and Report only)
Consultants that do not perform direct supervision.
Strictly observe and report basis reporting to project owner.
b.
Oil & Gas Consultants
(Other than Observe and Report)
Involved with direct supervision, control or oversight.
Acting as project manager or controller on behalf of owner.
c.
Oil & Gas Consultants (other)
Describe below:
d.
Is the Applicant responsible for hiring sub-contractors?
e.
If the Applicant is NOT responsible for hiring sub-contractors, who is?
f.
Years of experience in well site consulting?
8. Enter firm’s gross revenue for the last three years:
% Over Water: % $
$
$
Estimated gross revenue for the upcoming policy year:
Land:
1
st
prior policy year’s revenue
2
nd
prior policy year’s revenue
Yes No
E-PAC Oil and Gas Risks
Page 1 of 2
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
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9.
Please provide the percentage of gross revenue attributed to the following services or operations.
Must be equal to 100%
Well Site Consulting Services
Well site consultants that do not directly supervise. Strictly observe and report to project owner / operator.
%
Well site consultants with direct supervision, control or oversight. Acting as project manager to project
owner / operator.
%
Well site consultants – Other (describe):
%
Roustabout & Oilfield Contracting Operations
Acidizing
%
Mechanical
%
Carpentry
%
Meter / Gauge Readers
%
Casing Installation / Recovery
%
Owner / Operator of Oil & Gas Leases
%
Cementing / Paving (street or road
construction)
%
Painting
%
Perforation Services
%
Concrete ( not casing completion)
%
Pesticide / Herbicide Application
%
Dredging (including cleaning out of mud pits)
%
Pipe Line Construction
%
Drilling
%
Plumbing
%
Electrical
%
Pumper / Gauger Operations
%
Equipment Rental
%
Pumpjack / Well Site Maintenance
%
Fabrication / Manufacturing
%
Rig Erection / Dismantling
%
Fencing
%
Tank Battery Erection
%
Fishing Contractors
%
Water Hauler (clean water and / or dirty water)
%
Flow back Work
%
Welding
%
General Site Cleanup – Revegetation
%
Well Logging Services
%
General Site Preparation (land cleaning /
excavation / grading)
%
Wireline Services
%
Geophysical Exploration
%
Other (please describe):
%
Hot Oil Works
%
10.
Sublet Services
a.
Are certificates of insurance from sub-contractors kept on file?
Yes
No
b.
Are all sub-contractors hired under written contract?
Yes
No
c.
Do sub contracts contain indemnification provisions in favor of the Applicant?
Yes
No
d.
Is the Applicant named as additional insured on sub-contractor’s policies?
Yes
No
e.
Does the Applicant require a waiver of subrogation endorsement from sub-contractors?
Yes
No
f.
What is the estimated cost of sub-contracted work for the next fiscal year? $
11.
Submittals Required
Attach a resume for each of the Applicant’s principals, supervisors and well site consultants, as applicable.
This application is to be used in conjunction with a completed E-PAC Primary Application. The Undersigned states that
he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable
inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete
and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes prior to
the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
_________________________________________________
APPLICANT: (Signature of Owner of Officer of Corporation)
Date
APPLICANT: (Print Name and Title)
E-PAC Oil and Gas Risks
Page 2 of 2
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
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- OIL & GAS RISK SUPPLEMENTAL APPLICATION Oil (Philadelphia Insurance Companies)

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Completed 7 November 2020

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