Scottsdale Insurance Company Columbus, Ohio 43215 Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive Columbus, Ohio 43215 Scottsdale, Arizona Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale Indemnity Company Scottsdale, Arizona 85258 Home Office: One Nationwide Plaza 1-800-423-7675 Fax (480) 483-6752 • www.scottsdaleins.com OIL AND GAS CONTRACTORS SUPPLEMENT Applicant’s Name: Agency Name: Physical Address: Agent: Address: Mailing Address: E-mail: Website Address: Phone: PROPOSED EFFECTIVE DATE: From To , Standard Time at the address of the Applicant PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE APPLICABLE” “NOT General Information 1. What Coverage Extensions are requested: Blanket Additional Insured Blanket Waiver of Subrogation Underground Resources Underground Equipment Non-Owned Watercraft Limitation Deletion In Rem Pollution 2. Number of Years in Business: If under five years, how many years of experience do you have in the Oil & Gas Industry? 3. Number of Employees: Are there any leased employees? Yes No 4. The Insured’s company is: Individual Partnership Corporation Joint Venture Other: 5. Description of operations for each Named Insured: 6. Are any operations conducted offshore? Yes No If yes, what is the percentage of overall operations? % 7. Are any operations conducted on inland waterways? Yes No If yes, what is the percentage of overall operations? % 8. Receipts History—Past five years Year: Receipts:
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 • Fax (480) 483-6752 www.scottsdaleins.com OIL AND GAS CONTRACTORS SUPPLEMENT Applicant’s Name: Physical Address: Mailing Address: Website Address: Agency Name: Agent: Address: E-mail: Phone: PROPOSED EFFECTIVE DATE: From To , Standard Time at the address of the Applicant PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” General Information 1. What Coverage Extensions are requested: Blanket Additional Insured Blanket Waiver of Subrogation Underground Resources Underground Equipment Non-Owned Watercraft Limitation Deletion In Rem Pollution 2. Number of Years in Business: If under five years, how many years of experience do you have in the Oil & Gas Industry? 3. Number of Employees: Are there any leased employees? Yes No 4. The Insured’s company is: Individual Partnership Corporation Joint Venture Other: 5. Description of operations for each Named Insured: 6. Are any operations conducted offshore? Yes No If yes, what is the percentage of overall operations? % 7. Are any operations conducted on inland waterways? Yes No If yes, what is the percentage of overall operations? % 8. Receipts History—Past five years Year: Receipts:
Scottsdale-Oil-and-Gas-Contractors-Supplement.docx