Oil & Gas Consultants & Related Services Liability Insurance

Section 1: APPLICANT INFORMATION

Name of the Insured *
Contact Person
Address *
.
City *
Province *

Postal Code *
Business Phone #
Mobile Phone #
Home Phone #
Email *
Effective Date of Coverage

Section 2: GENERAL LIABILITY UNDERWRITING INFORMATION

Full Description of Business Operations

Total Receipts ($):

Operations Background

Area(s) of operations: British Columbia Alberta Saskatchewan
Manitoba Ontario Quebec Newfoundland and Labrador
New Brunswick Nova Scotia Prince Edward Island

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

USA Exposure: Yes No

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

Total Number of Employees: Full-Time / Part-Time
Year Business Established
Years Experience of the Principal/Partners

Insured's Qualifications

List all certificates & any other qualifications

Has the Applicant ever had Certification License revoked? Yes No
If yes, provide details:

Does the insured work directly with tools or equipment? Yes No
If yes, please describe:

Does the insured assemble the bits/tools used for drilling? Yes No
If yes, please describe assembly:

Describe the type and length of previous oilfield experience:

Describe any other training that is not mentioned above :

Does the insured perform any manual work? Yes No
If yes, please describe:

Section 3: Miscellaneous

Please provide any additional information that may be pertinent in the assessment of this Applicant:

Section 4: Insurance & Loss History Information

Previous Insurer
Policy #
Property Damage Deductible on prior policy? Yes No
If yes, Amount ($):

Section 5: Claims

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

Liability
Any claims in last five years? Yes No
If yes, Amount ($):
Describe Liability claim(s)

Property
Any claims in last five years? Yes No
If yes, Amount ($):
Describe Property claim(s)

Section 6: Insurance Requirements

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

Referral

Referred by:

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:

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
The Insured contravenes a term of the Contract or commits a fraud; or
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 *:

Financial Products Disclosure

Canadian Special Risks has an exclusive contract with Chubb Insurance Canada and represent products available through them. Canadian Special Risks also represents Cansure, and other companies as arranged by Cansure. No insurer holds any ownership interest in Canadian Special Risks, nor does Canadian Special Risks hold an interest in any insurance company. If you choose to purchase a product through Canadian Special Risks, Canadian Special Risks will be paid by the company that offers that product. Canadian Special Risks is compensated by a sales commission at the time of sale and may receive a renewal (or service) commission if you (our client) keep that policy in force. It is Canadian Special Risks duty to disclose any conflict of interest with you as our client, Canadian Special Risks confirms that there is no conflict of interest in regard to the proposed sales transaction that you are considering, and that Canadian Special Risks overall recommendation takes into consideration and is based on Canadian Special Risks analysis and assessment of your financial and security needs.

Canadian Special Risks Inc., a Westland Company

Head Office: #204, 5003 - 50 Avenue • Athabasca, AB T9S 1T2
Tel: (780) 732-3605 • Fax: (780) 675-3883 • info@weldinginsure.ca

Oil & Gas Consultants and Related Services Liability Application