3 4 Care, Custody & Control *Producing/Shut-In/Salt Disposal/Temporarily Abandoned/Plugged and Abandoned, etc. 9) Retention / Deductible Requested (100%): Drilling Workover/Recompletion All Other* Area Retention/Deductible Retention/Deductible Retention/Deductible 1 2 2W 3 4 Care, Custody & Control *Producing/Shut-In/Salt Water Disposal/Temporarily Abandoned/Plugged and Abandoned, etc. 10) Coverage Requested ("X” all that apply): Unlimited Redrilling Expenses Making Wells Safe Seepage and Pollution Deliberate Well Firing Care, Custody and Control Multi-Well Pad Underground Blowout Farmout Priority of Payments Turnkey Endorsement Contingent Venture Liability Other (please specify) Casing Well Failure 11) Loss Record (last five insured and/or uninsured): Date of Loss Description of Loss Net Total Incurred (including any defense/loss adjustment expense) If No claims last five years, check here: 12) Has any Insurer canceled or declined to provide Control of Well insurance for the Assured: Yes No
3 4 Care, Custody & Control *Producing/Shut-In/Salt Disposal/Temporarily Abandoned/Plugged and Abandoned, etc. 9) Retention / Deductible Requested (100%): Drilling Workover/Recompletion All Other* Area Retention/Deductible Retention/Deductible Retention/Deductible 1 2 2W 3 4 Care, Custody & Control *Producing/Shut-In/Salt Water Disposal/Temporarily Abandoned/Plugged and Abandoned, etc. 10) Coverage Requested ("X” all that apply): Unlimited Redrilling Expenses Making Wells Safe Seepage and Pollution Deliberate Well Firing Care, Custody and Control Multi-Well Pad Underground Blowout Farmout Priority of Payments Turnkey Endorsement Contingent Venture Liability Other (please specify) Casing Well Failure 11) Loss Record (last five insured and/or uninsured): Date of Loss Description of Loss Net Total Incurred (including any defense/loss adjustment expense) If No claims last five years, check here: 12) Has any Insurer canceled or declined to provide Control of Well insurance for the Assured: Yes No
Control-of-Well-Application.docx