Form MMS-1019 Insurance Certificate

U.S. Department of the Interior OMB Control No. 1010-0106

Bureau of Ocean Energy Management, OMB Approval Expires: xx/xx/xxxx

INSURANCE CERTIFICATE

Enforcement and Regulation

OIL POLLUTION ACT OF 1990 APPLICATION FOR CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY

(TYPE OF PRINT ALL INFORMATION EXCEPT SIGNATURES)

1. DESIGNATED APPLICANT: ______________________________________________________ ___________________________

COMPANY LEGAL NAME BOEM COMPANY NUMBER

2. THE AMOUNT OF INSURANCE COVERAGE ESTABLISHED AS EVIDENCE OF OIL SPILL FINANCIAL RESPONSIBILITY FOR THE DESIGNATED APPLICANT (HEREAFTER THE INSURED) BY THE NAMED INSURERS

IN COMPLIANCE WITH TITLE I OF THE OIL POLLUTION ACT OF 1990 (HEREAFTER THE ACT) AND PART 253 OF TITLE 30, CODE OF FEDERAL REGULATIONS (CFR), FOR ANY ONE INCIDENT IS:

FROM $________________________ TO: $________________________

STARTING AMOUNT ABOVE ANY UPPER LIMIT OF

DEDUCTIBLE OR EXCESS AMOUNT THIS INSURANCE LAYER

THE FOLLOWING INSURANCE OPTION HAS BEEN SELECTED TO PROVIDE THIS COVERAGE:

□ Full Option--Insurance is provided for the first full $_______ million without deductible.

□ Deductible Option--Insurance is provided for the amount of $_______ million less the deductible amount of $_______ .

□ Excess Option--Insurance is provided for the amount of $_______ million in excess of the amount of $_______ million.

3. THIS COVERAGE IS EFFECTIVE: ____________ AT _________ AND EXPIRES: ____________ AT _________

DATE CENTRAL STANDARD DATE CENTRAL STANDARD

TIME TIME

The termination date and time will be the date and time this instrument expires or, if prior thereto, the date cancellation is effective. Expiration will be effective with or without written notice. Termination does not affect the liability of the insurers in connection with an oil discharge occurring before the termination date (reference 30 CFR 253.41).

4. INSURANCE AGENT OR BROKER FOR THIS INSURANCE CERTIFICATE:

________________________________________________________________________ ___________________

COMPANY NAME BOEM COMPANY NUMBER

____________________________________________________________________________________________________________________________________________

ADDRESS

____________________________________________________________________________________________________________________________________________

CITY STATE COUNTRY (If not U.S.A. ZIP CODE

( )___________________________ ( )___________________________ ____________________________

AREA CODE and TELEPHONE NUMBER AREA CODE and FAX NUMBER E-MAIL ADDRESS

AS AN AUTHORIZED REPRESENTATIVE OF THE INSURANCE AGENT OR BROKER IDENTIFIED ABOVE, I CERTIFY THAT THE INFORMATION CONTAINED IN THIS INSURANCE CERTIFICATION IS ACCURATE AND CORRECT, AND THAT QUOTA SHARES TOTAL 100 PERCENT FOR THIS INSURANCE CERTIFICATE, AND THAT THIS INSURANCE CERTIFICATE AND THE NAMED INSURERS COMPLY WITH THE REQUIREMENTS STATED IN 30 CFR 253.29. THE IDENTIFIED INSURANCE AGENT OR BROKER AGREES TO MAINTAIN AND PROVIDE TO THE DESIGNATED APPLICANT AND THE BUREAU OF OCEAN ENERGY MANAGEMENT, REGULATION, AND ENFORCEMENT (BOEM), ON DEMAND, ANY DELEGATIONS OF AUTHORITY TO A BROKER OR AN UNDERWRITER OF ANOTHER INSURER OR UNDERWRITING MANAGER TO BIND A NAMED INSURER TO ALL RISKS AND LIABILITIES SPECIFIED IN TITLE I OF THE ACT. THE IDENTIFIED INSURANCE AGENT OR BROKER FURTHER AGREES TO NOTIFY, IN ACCORDANCE WITH 30 CFR 253.41, THE DESIGNATED APPLICANT AND THE BOEM OIL SPILL FINANCIAL RESPONSIBILITY PROGRAM, BY WRITTEN NOTICE SENT BY CERTIFIED MAIL, OF THE INTENT TO TERMINATE THIS INSURANCE CERTIFICATE PRIOR TO THE END OF THE COVERAGE PERIOD SPECIFIED ABOVE.

___________________________________________________________________ ___________________________

NAME SIGNATURE

________________________________________________________________________________________________ _______________________________________

TITLE DATE

BOEM FORM MMS-1019 (Mo/Year – Supersedes all previous versions of form MMS-1019 which may not be used). Page 1 of 4

5. THE NAMED INSURERS, LISTED BEOW, CERTIFY THAT THE DESIGNATED APPLICANT IS INSURED BY THE NAMED INSURERS FOR THE OFFSHORE FACILITIES, SPECIFIED BY THE SELECTED OFFSHORE FACILITY COVERAGE OPTION, AGAINST LIABILITY FOR REMOVAL COSTS AND DAMAGES TO WHICH THE DESIGNATED APPLICANT COULD BE SUBJECTED UNDER TITLE I OF THE ACT AND 30 CFR 253 WITHIN THE INSURANCE LAYER SPECIFIED.

THE FOLLOWING OFFSHORE FACILITY COVERAGE OPTION HAS BEEN SELECTED:

□ General Option—All covered offshore facilities for which the Insured is the Designated Applicant.

□ Schedule Option— All covered offshore facilities on the Designated Applicant’s attached information form

and schedule of properties forms, effective _________________________.

DATE

6. THE NAMED INSURERS AGREE THAT ANY SUIT OR CLAIM FOR WHICH THE INSURED MAY BE LIABLE UNDER TITLE I OF THE ACT MAY BE BROUGHT DIRECTLY AGAINST THE NAMED INSURERS FOR CLAIMS ASSERTED BY THE U.S. GOVERNMENT OR, IN THE CASE OF THE INSURED’S INSOLVENCY OR PETITION FOR BANKRUPTCY UNDER TITLE 7 OR 11, U.S.C. 101, FOR CLAIMS ASSERTED BY OTHER CLAIMANTS THROUGH THE U.S. COAST GUARD NATIONAL POLLUTION FUNDS CENTER.

7. THE NAMED INSURERS AGREE THAT IN THE EVENT OF A DIRECT CLAIM, THE NAMED INSURERS WILL BE ENTITLED TO INVOKE ONLY (1) THE RIGHTS AND DEFENSES PERMITTED BY TITLE I OF THE ACT TO THE INSURED, AND (2) THE DEFENSE THAT THE INCIDENT GIVING RISE TO THE CLAIM WAS CAUSED BY THE WILLFUL MISCONDUCT OF THE INSURED.

8. THE NAMED INSURERS DESIGNATE THE FOLLOWING U.S. AGENT FOR SERVICE OF PROCESS FOR THIS INSURANCE CERTIFICATE:

________________________________________________________________________ ___________________

NAME BOEM COMPANY NUMBER

____________________________________________________________________________________________________________________________________________

ADDRESS

____________________________________________________________________________________________________________________________________________

CITY STATE ZIP CODE

( )___________________________ ( )___________________________ ____________________________

AREA CODE and TELEPHONE NUMBER AREA CODE and FAX NUMBER E-MAIL ADDRESS

If the designated U.S. Agent for Service of Process cannot be served due to death, disability, or unavailability, the Director, U.S. Coast Guard National Pollution Funds Center, is the U.S. Agent for Service of Process.

BOEM FORM MMS-1019 (December 2007 – Supersedes all previous versions of form MMS-1019 which may not be used). Page 2 of 4

9. THE FOLLOWING NAMED INSURERS HEREBY CERTIFY THEIR PARTICIPATION ON THIS INSTRUMENT:

BOEM ID NUMBER	INSURER’S NAME	QUOTA SHARE	AUTHORIZED SIGNATURE	NAME AND TITLE OF BINDING OFFICIAL	INSURANCERATING	INSURANCE RATING SERVICE	DATE OF RATING (MM/YY)
	SUBTOTAL OF QUOTA SHARE

BOEM FORM MMS-1019 (December 2007 – Supersedes all previous versions of form MMS-1019 which may not be used). Page 3 of 4

9. THE FOLLOWING NAMED INSURERS HEREBY CERTIFY THEIR PARTICIPATION ON THIS INSTRUMENT (continued):

BOEM ID NUMBER	INSURER’S NAME	QUOTA SHARE	AUTHORIZED SIGNATURE	NAME AND TITLE OF BINDING OFFICIAL	INSURANCE RATING	INSURANCE RATING SERVICE	DATE OF RATING (MM/YY)
SUBTOTAL FROM PREVIOUS PAGE
	TOTAL QUOTA SHARE (MUST EQUAL 100%)

BOEM FORM MMS-1019 (December 2007 – Supersedes all previous versions of form MMS-1019 which may not be used). Page 4 of 4