GENERAL LIABILITY SUPPLEMENT - OPERATOR / NON-OPERATOR by 6en78I

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									GENERAL LIABILITY SUPPLEMENT - OPERATOR / NON-OPERATOR

I.   APPLICANT INFORMATION:
1.   Applicant is (check all that apply):
             An investor owning a non-operating working interest in oil and/or gas wells.
             An operator of record managing lease operations for working interest owners.
             An operator of record that utilizes a contract lease operator.
             A lease operator by contract who does not have a working interest in the wells.
             A lease operator by contract with a working interest in the wells.
             An operator or non-operator of gathering systems and/or pipeline(s) - attach applicable Supplement.
             An operator or non-operator of a gas plant(s) - attach applicable Supplement.

2.   Number of employees:

3.   Gross Payroll:                          Gross Overwater Payroll (if applicable):                        Jones Act
                                                                                                             USL&H

4.   Estimated annual gross revenue: Domestic:                                     Foreign:

5.   Please attach company loss runs for the previous six (6) years.

6.   Safety Information:
          Applicant has regularly scheduled safety meetings:                            Yes         No
          Applicant has drug/alcohol testing program:                                   Yes         No
          Applicant has written regular equipment maintenance program:                  Yes         No
          Applicant obtains Motor Vehicle Reports (MVRs) on all drivers:                Yes         No
          Applicant has written screening process for new employees:                    Yes         No
          Applicant has written safety program:                                         Yes         No
          Applicant has written safety incentive program:                               Yes         No
          Applicant conducts field safety inspections of work in progress:              Yes         No
          Applicant has a training program for new employees:                           Yes         No
          Applicant has a training program for supervisors/management:                  Yes         No
          Applicant evaluates accidents to determine cause / takes action to            Yes         No
           to prevent reoccurrence:

7.   Does the Applicant require Hired/Non-owned Automobile Liability coverage? Yes                    No

8.   Does the Applicant own or operate watercraft?                                             Yes    No
         If Yes, attach a schedule including type of watercraft, age and length.

9.   If the Applicant's expiring CGL contains a retroactive date, what is the date and to what coverage does it
     apply?

10. What Control of Well limit(s) does the Applicant carry?
     a.     Does the Applicant’s Control of Well policy include pollution coverage?                  Yes           No
     b.     Does the Applicant’s Control of Well policy cover all drilling wells?                    Yes           No
     c.     Does the Applicant’s Control of Well policy cover all other wells in which               Yes           No
            the Applicant has an interest?

     Please explain/elaborate concerning any "No" answers.

In respect of wells to be drilled, wells to be worked over and Producing, etc. wells, please
thoroughly complete the Excel worksheets provided (including, if applicable, the "townsite"
tab in respect of wells located within municipalities and the H2S tab in respect of wells with
significant H2S content).

General Liability Supplement - Oper./Non-op.                   Page 1 of 3                           Form 407 (Ed. 09/11)
II.   OPERATOR (complete this section if it pertains to the Applicant's operations):
1.    How many years experience as an operator?
           If Applicant has less than five years of experience, please attach resumes / employment histories of key
           personnel / principals.

2.    Does the Applicant lease employees?                                                              Yes            No
           If Yes, please explain.

3.    Does the Applicant require Stop Gap Coverage?                                                    Yes            No
           If Yes, list states and gross payroll amount for each.

4.    What limits does Applicant require of their contractors?
       CGL/Excess Liability (including contractual)                                Control of Well (if applic.)

5.    Does the Applicant maintain an approved contractor list?                                         Yes            No

6.    Does the Applicant maintain a Master Service Agreement (MSA)?                                    Yes            No

7.    Does the Applicant’s MSA contain the following?
      a.     Contractors are required to carry CGL, including Contractual Liability and Pollution
             Liability, with limits of at least $1,000,000.                                            Yes            No
      b.     Mutual indemnity (hold harmless) agreements.                                              Yes            No
      c.     Contractors are required to include the Applicant as an Additional Insured.               Yes            No
      d.     Contractors are required to provide waivers of subrogation.                               Yes            No

8.    Does the Applicant have a system monitoring the currency of contractors' MSAs
      and Certificates of Insurance?                                                                   Yes            No

9.    Does the Applicant own/operate any vehicles/equipment that are not subject to
      compulsory or financial responsibility laws (mobile equipment)?                                  Yes            No
           If Yes, please attach schedule (in Excel) of such vehicles/equipment.

10. Does the Applicant operate disposal wells primarily for third party use?                           Yes            No
       If Yes, please describe controls in place for third party disposal.

11. Does the Applicant have a Spill Prevention Control & Countermeasure Plan?                          Yes            No
       If Yes, please attach an electronic copy of the Plan.

12. If the Applicant is involved with multi-stage hydraulic fracturing (fracing) operations, please answer the
    following questions (if answers vary per resource play / location / region, please elaborate):

           a. Does the Applicant require that only U.S.-manufactured steel is used?                    Yes            No
               If No, please explain.

           b. Does the Applicant require that cement is run high enough to cover all                   Yes            No
              potentially productive and/or corrosive formations?
               If No, please explain.

           c. Does the Applicant require that fluids and proppants delivered to the well               Yes            No
              site are verified against the material specifications of the frac job?
               If Yes, who is responsible for verification and record keeping?




General Liability Supplement - Oper./Non-op.                    Page 2 of 3                             Form 407 (Ed. 09/11)
       d. Does the Applicant require that water delivered to the well site to be used for fracing
          is tested?                                                                        Yes            No
           If Yes, who is responsible for testing and record keeping?
          If No, what is the Applicant's procedure in this respect?

       e. What is the depth of the deepest underground source of drinking water (USDW)
          through which the Applicant is drilling?

       f. Does the Applicant require pre-drilling and post-drilling testing of the USDW? Yes               No

       g. Does the Applicant require that micro seismic or other recording /               Yes             No
          monitoring takes place during drilling?

       h. How does the Applicant dispose of recovered frac fluids? Recycle, disposal well, treatment
          plant or other?

       i. What maximum pressure (as a percentage of the burst specification of the casing) does the
          Applicant allow?

       j. When designing their casing program, does the Applicant give consideration Yes                   No
          to cycling due to multi-stage fracs?

       k. Is the Applicant conducting any through-tubing frac jobs?                        Yes             No
          If Yes, is an isolation tool used to protect the tree?                           Yes             No

13. Please attach a schedule of all third party entities (including addresses) that require specifically endorsed
    documentation in the Applicant's GL e.g. Notice of Cancellation or Material Change, Additional Insureds,
    Described Lender, Marcel.


III. NON-OPERATOR (complete this section if it pertains to the Applicant's operations):
1.   Do the Applicant's operators' CGLs include the Applicant as an Additional Insured? Yes                No
2.   Does the Applicant obtain Certificates of Insurance from their operators?             Yes             No




General Liability Supplement - Oper./Non-op.               Page 3 of 3                      Form 407 (Ed. 09/11)

								
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