MMS-1018 Self-Insurance or Idemnity Information

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

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

Regulation and Enforcement

SELF-INSURANCE OR INDEMNITY INFORMATION

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

(TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES

1. DESIGNATED APPLICANT: ______________________________________________________ ___________________________

COMPANY LEGAL NAME BOEMRE COMPANY NUMBER

2. FOR THE PURPOSE OF THIS APPLICATION THE UNDERSIGNED IS ACTING IN THE FOLLOWING CAPACITY:

SELF-INSURER (30 CFR 253.21 AND 30 CFR 253.41) INDEMNITOR (30 CFR 253.30 AND 30 CFR 253.41)

3. THE AMOUNT OF COVERAGE FOR WHICH EVIDENCE OF OIL SPILL FINANCIAL RESPONSIBILITY IS BEING ESTABLISHED IS:

FROM	$ 0		TO	$
	LOWER LIMIT			UPPER LIMIT (Must be Completed)

4. THIS COVERAGE IS EFFECTIVE: _________ AND EXPIRES ON THE FIRST CALENDAR DAY OF THE FIFTH MONTH

DATE

AFTER THE CLOSE OF THE SELF-INSURER’S OR INDEMNITOR’S FISCAL YEAR, WHICH ENDS: _________ .

DATE

5. SELF-INSURER OR INDEMNITOR PROVIDING EVIDENCE OF OIL SPILL FINANCIAL RESPONSIBILITY FOR THE

DESIGNATED APPLICANT: ______________________________________________________ ___________________________

COMPANY LEGAL NAME BOEMRE COMPANY NUMBER

____________________________________________________________________________________________________________________________________________

ADDRESS

____________________________________________________________________________________________________________________________________________

CITY STATE ZIP CODE

__________________________________________________________________ __________________________________________________________________

CONTACT PERSON FOR CLAIMS CONTACT PERSON’S TITLE

( )___________________________ ( )___________________________ ____________________________

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

6. THE UNDERSIGNED, AS AN OFFICER OR DESIGNATED AGENT OF THE ABOVE-NAMED SELF-INSURER OR INDEMNITOR COMPANY, AGREES TO THE CONDITIONS STATED IN 30 CFR 253.21 THROUGH 30 CFR 253.28,

30 CFR 253.30, 30 CFR 253.40, AND 30 CFR 253.41, AND TO NOTIFY THE OIL SPILL FINANCIAL RESPONSIBILITY PROGRAM IN THE EVENT THE DESIGNATED APPLICANT OR THE INDEMNITOR IS NO LONGER ABLE TO MAINTAIN EVIDENCE OF OIL SPILL FINANCIAL RESPONSIBILITY TO THE EXTENT STATED IN SECTION 3 ABOVE (REFERENCE 30 CFR 253.15).

__________________________________________________________ ____________________________________

NAME SIGNATURE

______________________________________________________________________________________________________ ___________________________

TITLE DATE

7. THE SELF-INSURER’S OR INDEMNITOR’S U.S. AGENT FOR SERVICE OF PROCESS IS:

________________________________________________________________________ ___________________

NAME BOEMRE 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.

BOEMRE FORM MMS-1018 (Mo/Year – Supersedes all previous versions of form MMS-1018 which may not be used). Page 1 of 1