APPLICATION FORM CONTROL OF WELL INSURANCE 1) Name of Assured (First Named Assured and other Named Assureds): 2) Address of Assured: 3) Assured is all that apply): An oil and/or gas lease operator An oil and/or gas lease non-operator An oil and/or gas contract lease operator A drilling contractor How many years has the Assured been in business (if less than five years, provide principals experience): 5) Name of Principals: 6) Proposed Policy Period: 7) Account History last five years: – Year Carrier Limits Actual/Estimated Premium 8) Limit of Liability Requested (100%): Drilling Workover/Recompletion All Other* Area Limit of Liability Limit of Liability Limit of Liability 1 2 2W
APPLICATION FORM CONTROL OF WELL INSURANCE 1) Name of Assured (First Named Assured and other Named Assureds): 2) Address of Assured: 3) Assured is all that apply): An oil and/or gas lease operator An oil and/or gas lease non-operator An oil and/or gas contract lease operator A drilling contractor How many years has the Assured been in business (if less than five years, provide principals experience): 5) Name of Principals: 6) Proposed Policy Period: 7) Account History – last five years: Year Carrier Limits Actual/Estimated Premium 8) Limit of Liability Requested (100%): Drilling Workover/Recompletion All Other* Area Limit of Liability Limit of Liability Limit of Liability 1 2 2W