Oil and Natural Gas Industry - PDF

							Oil and Natural Gas Industry


                                                                                                                    Questionnaire




Name in full

Date of birth
                                                   |       |           |

Application number or reference


Please answer the questions by giving us all the information we ask for. All the questions we ask are relevant and important and must be
answered accurately and completely to the best of your knowledge. If they are not, we will have the legal right to cancel any policy issued and
not pay a claim. You should not assume that any information will be obtained from a doctor or any other source that we may write to, or from
any other application.

Your replies will be treated in the strictest confidence and will form part of your application for insurance. Please place the completed
questionnaire in a sealed envelope addressed to the Chief Medical Officer at Friends Provident.

After completing the relevant sections, please read them carefully and then sign the Declaration at the end of this questionnaire. If you run out
of space when writing your answers, feel free to continue on a separate sheet of paper but please make reference to this on the questionnaire.

Offshore Exploration Worldwide
1 What is your occupation:

    Bargemaster (Captain)                                                        Pipelaying Barges (give details below)

    Catering Staff                                                               Radio Operator

    Cementer                                                                     Rig Electrician

    Control Room Operator                                                        Rig Mechanic

    Crane Operator                                                               Rig Medic

    Derrickman (Topman)                                                          Rig Welder

    Driller                                                                      Rigger

    Drilling Engineer                                                            Roughneck

    Drilling Supervisor                                                          Roustabout

    Geologist                                                                    Sub Sea Engineer

    Logger (Electric)                                                            Supply Ship (give details below)

    Motorman                                                                     Survey Ship (give details below)

    Mud Engineer (Mud Man)                                                       Tool Pusher

    Mud Logger                                                                   Tool Pusher (Assistant)

    Petroleum Engineer                                                           Well Tester

   If your occupation is not listed above or if
   further details are needed, please give
   information here eg Job title, brief details.


   Do you use explosives?                Yes               No                 Is manual work involved?        Yes                No
                                                                                                                      Continued on the next page
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    FAILURE TO GIVE ACCURATE AND COMPLETE INFORMATION MAY RESULT IN NON PAYMENT OF A CLAIM

2 Name of Employer

3 Geographical area of operations

4a Work pattern offshore                                                   Weeks on                                      Weeks off


4b If only occasional visits,how many each
   year and duration of visit


Land operations abroad
5 Are you likely to work on land operations abroad?                  Yes                   If Yes, please complete questions 6–9

                                                                      No

6 Where are you likely to work?




7 Will you work in remote areas?                                     Yes                    If Yes, how near in terms of hours is medical aid?


                                                                      No




8 What job are you likely to do?




9 If you are likely to fly other than as a                          Number of hours p.a.
  passenger in an aircraft licensed to carry
  passengers and flown by a pilot holding a
  commercial licence, please give details.

                                                                    Reason for flight




                                                                    Areas of flying




Declaration
I declare that the answers I have given are to the best of my knowledge and belief true, and that I have not withheld any fact.

I agree that this questionnaire will form part of my application for insurance to Friends Provident and that failure to disclose a fact or the giving
of false information may invalidate any future claim.

 Signature


 Date




Friends Provident Life Assurance Limited
Registered and Head Office: Pixham End, Dorking, Surrey RH4 1QA
Incorporated company limited by shares and registered in England number 782698
Authorised and regulated by the Financial Services Authority
www.friendsprovident.com     Telephone 0845 602 9189
FRIENDS® and ‘the power of FRIENDS®’ are registered trade marks of Friends Provident in the UK and other countries

XF28 02.09