(Fields marked * are required.)

Oil & Gas Consultants and Related Services Liability Application

Section 1: APPLICANT INFORMATION














Section 2: GENERAL LIABILITY UNDERWRITING INFORMATION



Operations Background




(Select at least one area of operations. You may select more than one area.)


Yes No

Please note that we do not offer coverage in the United States.

Total Number of Employees: /


Insured's Qualifications



Yes No


Yes No


Yes No






Yes No


Section 3: Miscellaneous


Section 4: Insurance & Loss History Information



Yes No

Section 5: Claims

Claims Experience: Describe all claims in the last five years (include all relevant details, such as dates)

Liability
Yes No



Property
Yes No


Section 6: Insurance Requirements

Commercial General Liability
$1,000,000 $2,000,000 $3,000,000 $5,000,000

Referral

NOTICE TO APPLICANT

Consumer and previous insurer reports containing personal, credit, factual or investigative information about the applicant may be sought in connection with this Applicant for Insurance or any renewal, extension or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of Insurance. The policy may be deemed to be void and claims may be denied where:
  1. An Applicant for a contract:
    1. Gives false or erroneous information to the prejudice of the insurer, or
    2. Knowingly misrepresents or fails to disclose in the Application any fact required to be stated therein; or
  2. The Insured contravenes a term of the Contract or commits a fraud; or
  3. The Insured willfully makes a false statement in respect of a claim under the contract

YOU CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENTS.

YOU ARE IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE AGREEMENT.

I accept the terms *: