Lease Operator

Lease Operator APPLICATION Chubb Insurance Company of Canada General Liability, Pollution Liability and Umbrella Liability By completing this APPLICATION you are applying for coverage with Chubb Insurance Company of Canada (the "Company") I. APPLICANT INFORMATION 1. 2. 3. 4. 5. Applicant Name: Applicant Address: Phone: ( ) Fax: ( ) E-mail address and/or Web site address: Describe all operations other than oil and gas exploration, development and production (to be insured or not): 6. 7. 8. Describe area/region of Canadian operations: Describe area/region of all other operations: Provide revenues for the upcoming year: (Please breakdown by country/region and operations, if applicable.) 9. Is Named Insured status requested for any other entities? If yes, give name and operation of each: Yes No 10. Do any requested Named Insureds have subsidiary, related or affiliated companies which are not stated in 1 or 9 above (to be insured or not)? If yes, please describe: 11. Operations – Check all that apply: Lease Operator Promoter (attach details) Operator by contract Non operating working interest owner Yes No Developer (attach details) Other (attach details) Wet Operations (operations in, over or upon any watercourse, body of water, bog, marsh, swamp or wetland) If Wet Operations is checked, complete the Lease Operator - Wet Operations Application Supplement. All information pertaining to wet operations should be provided on that “Wet Operations Application Supplement”. Information provided on the “Lease Operator Application Supplement” should be limited to land operations only. GENERAL LIABILITY AND POLLUTION LIABILITY II. OPERATOR Limit Of Insurance required General Liability Pollution Liability Yes Yes No No $ $ Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 1 of 8 A. ASSETS* (producing, injection, shut-in, suspended and workover) for which you are Operator/Operator by contract): CANADA Gross Net Gross U.S.A. Net 1. Number of Wells: Operated/Producing Operated/Non-Producing Non-Operated/Producing Non-Operated/Non-Producing 2. Gas Plants: Operated Non-Operated 3. Compressor Stations: Operated Non-Operated 4. Batteries: Operated Non-Operated 5. Km of Pipelines: (excluding gathering systems) Oil Gas B. PRODUCTION 1. 2. What percentage of your wells are: Average current production: Gas? % Oil? Oil (bbl/d): % Gas (mcf/d): *In place of completing above, applicant may provide a well schedule containing the information requested. 3. Are any wells within 1000‟/305m of an occupied structure? If yes, attach well descriptions and locations. 4. Are any wells within corporate limits of a city or town? If yes, attach well descriptions and locations. 5. Are any wells located in a railroad right-of-way? If yes, attach well descriptions and locations. 6. Do you now, or have you ever, provided any domestic gas connection services beyond providing a tap? (e.g. laying pipe, hook up to house, install or maintain meters or regulators, etc.) If yes, please describe: 7. NET WELLS TO-BE-DRILLED in next 12 months for which you are Operator or Operator by Contract: Yes No Yes No Yes No Yes No Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 2 of 8 0‟ - 2,500‟ / 0m - 762m 5,001‟ - 7,500‟ / 1525m - 2286m 8. 9. 2,501‟ - 5,000‟ / 763m - 1524m over 7,500‟ / over 2286m How many wells were drilled for you by subcontractors in the last 12 months? Do you have plans for any directional wells in the next 12 months? If yes, attach details. Yes No 10. PIPELINE for which you are responsible as Operator or Operator by Contract: a. total length with outside diameter 6”/15cm or less: b. length of 6”/15cm or less transporting product of others: c. total length with outside diameter over 6”/15cm: (indicate units) (indicate units) (indicate units) (indicate units) inches cm d. length over 6”/15cm transporting product of others: 11. Indicate diameter of largest pipeline you operate: 12. Indicate maximum operating and design pressure of pipeline you operate: a. maximum operating pressure: b. design pressure: psi psi kPa kPa Yes No 13. Do you operate any pipelines above 2/3 design pressure? If yes, attach details. 14. Do you operate any pipelines thru town, cities or populated areas? If yes, attach details. Yes No 15. Do you operate any pipelines crossing railways, roads, or water? If yes, attach details. Yes No 16. Do you operate any pipelines supply end users other than house gas? If yes, attach details. Yes No 17. Age of Pipeline: 18. Is the pipeline cathodically protected? If yes, attach details. 19. Who is the operator of the pipeline? 20. What type of oil is in this pipeline? 21. Do you have a regular maintenance program in effect? (How often, checked daily, by whom, how often is the pipeline pigged?) Yes No 22. Is there a leak detection system in place? If yes, please describe: 23. Are shut off valves in place? Are they operated manually or by remote control? Yes No Yes No Please explain: 24. Is the pipeline SCADA monitored? If yes, attach details. 25. Where is the pipeline located? Yes No Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 3 of 8 26. Do you operate SECONDARY RECOVERY operations? If yes, attach details. 27. Do you operate or have an ownership interest in any GAS PROCESSING or GASOLINE RECOVERY (distillate) plants? If yes, attach details. 28. Do you operate any GAS SWEETENING plants? If yes, attach details with ppm H2S and exposures within 1500'/450m. 29. Do you operate any SALT WATER DISPOSAL WELLS? If yes, attach details with number penetrating known producing zones. 30. Indicate operations performed by subcontractors and whether for yourself and/or for others: Yes No Yes No Yes No Yes No For Yourself Acidizing Casing Install &* Pull Cementing Drilling & Redrillling Equipment Inspect/Repair Fracturing Land Clearing & Grading Perforating Other (attach details) 31. How many field employees do you have? For Others Pipeline Operations Pumping & Gauging Rig & Equipment Hauling Rod & Tubing Replacement Swabbing Tank Cleaning & Painting Wireline Operations Pipeline Construction 32. Indicate which of the following you require of your SUBCONTRACTORS: Certificate of Insurance Additional Insured Status for yourself on subcontractor coverage Waiver of subrogation provision on subcontractor coverage Subcontractor's coverage endorsed to be primary 33. Do you require subcontractors to have a Master Service Agreement (MSA), CAODC or equivalent contract to be completed and on file in your office before they begin work for you? Yes No 34. Indicate the insurance coverages and limits you require for subcontractors? Coverages General Liability Blanket Contractual coverage Products/Completed Operations coverage Underground Resources coverage Pollution Auto Workers Compensation Umbrella Liability Limits Required $ $ $ $ $ $ N/A $ Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 4 of 8 35. Indicate how you contract for drilling work by the percentage applicable to each method: Not applicable (no drilling planned) No Contracts Used % % % Turnkey Day Work Footage CAODC CAODC CAODC Other (attach sample) Other (attach sample) Other (attach sample) 36. What amount do you expect to spend annually for subcontractors listed below? a. Lease Operations: b. Workover: c. Drilling: $ $ $ 37. a. Indicate the „Operator‟s Extra Expense‟ or „Cost of Control‟ or „Blowouts‟ coverage you carry: None All wells – producing, injection, shut-in, suspended, workover and wells being drilled Producing, injection, shut-in, suspended and workover only Wells being drilled only Other – Describe: b. c. What limits do you carry for this insurance? Does this coverage include pollution liability? $ Yes No Not applicable Yes No 38. Do you operate disposal/injection wells? If yes, please provide details including number of wells and materials injected: 39. Are all aboveground tanks (including crude stock tanks) diked to 150% of capacity? Yes No III. NON-OPERATING WORKING INTEREST 1. 2. Do you use CAPL (Canadian Association of Petroleum Landmen) contracts in joint venture agreements? ASSETS (producing, injection, shut-in, suspended and workover) in which you have a nonoperating working interest: a) b) Do you maintain current certificates of insurance from all operators? Are you named as an additional insured on all operators‟ policies? Yes No Yes Yes No No CLAIMS INFORMATION Please provide details of all reported claims against Applicant in the last five years. Please include claims in excess of $25,000 that were NOT REPORTED. NOTICE Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 5 of 8 The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to purchase, a policy. The Applicant will be advised if the Application for coverage is accepted. The Applicant hereby authorises the Company to make any inquiry in connection with this Application. MATERIAL CHANGE If there is any material change in the answers to the questions in this Application before the policy inception date, the Applicant must immediately notify the Company in writing, and any outstanding quotation may be modified or withdrawn. FALSE INFORMATION Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. DECLARATION AND SIGNATURE I have read the above Application. I declare that to the best of my knowledge and belief the statements and information in this Application and any attachments thereto are true, accurate and complete. This information is given to the Company for the specific purpose of obtaining insurance coverage. It is agreed that if any information given in this Application or in any attachments thereto is materially false, inaccurate or incomplete, the Company may deny coverage or cancel the policy. Date Signature of First Named Insured (May not be signed by Producer) Title Submitted by: Agency: Phone: E-mail: ( ) Fax: ( ) PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED TO BIND COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND BINDS THE COVERAGE. Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 6 of 8 UMBRELLA LIABILITY 1. 2. 3. 4. Coverage required? Including Pollution? Limit Of Insurance required: Automobile Number of vehicles: Yes Yes $ Private Passenger: Light Trucks (vans, pickups): Heavy Trucks: Others (Tractors, Buses): 5. a. Do you own, lease, or charter any aircraft? If yes, please describe activities: b. Do you purchase Non-Owned Aircraft Liability Insurance? If yes, what is your policy limit? 6. $ Yes No Yes No Yes No No No Do you own, lease, or charter any watercraft? If yes, please describe activities: NOTICE The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to purchase, a policy. The Applicant will be advised if the Application for coverage is accepted. MATERIAL CHANGE If there is any material change in the answers to the questions in this Application before the policy inception date, the Applicant must immediately notify the Company in writing, and any outstanding quotation may be modified or withdrawn. FALSE INFORMATION Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. DECLARATION AND SIGNATURE I have read the above Application. I declare that to the best of my knowledge and belief the statements and information in this Application and any attachments thereto are true, accurate and complete. This information is given to the Company for the specific purpose of obtaining insurance coverage. It is agreed that if any information given in this Application or in any attachments thereto is materially false, inaccurate or incomplete, the Company may deny coverage or cancel the policy. Date Signature of First Named Insured (May not be signed by Producer) Title Submitted by: Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 7 of 8 Agency: Phone: E-mail: ( ) Fax: ( ) PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED TO BIND COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND BINDS THE COVERAGE. Lease Operator APPLICATION - General Liability, Pollution Liability and Umbrella Liability Page 8 of 8