Form BOEM-1018 Self-Insurance Information

U.S. Department of the Interior OMB Control No.: _xxxxxxx

_{Bureau of Ocean Energy Management Expiration Date: xxxxxxxxx}

SELF-INSURANCE INFORMATION

RESPONSIBLE PARTY SELF-INSURANCE CERTIFICATION OF OIL SPILL FINANCIAL RESPONSIBILITY

IN ACCORDANCE WITH THE REQUIREMENTS OF THE OIL POLLUTION ACT OF 1990

(TYPE OR PRINT ALL INFORMATION EXCEPT SIGNATURES)

1. I, the undersigned, as the Authorized Representative of the Responsible Party (described in section 6), certifies that the Responsible Party is acting in the capacity of a Self-Insurer, in accordance with the requirements of 30 CFR 553.41.

2. The amount of coverage for which evidence of oil spill financial responsibility is being established by the Responsible Party using self-insurance is:

FROM	$	0		TO	$
		LOWER LIMIT			UPPER LIMIT (MUST BE COMPLETED)

3. This coverage is effective: and expires on the first calendar day of the fifth month

DATE

after the close of the Self-Insurer’s fiscal year, which ends: _______________________.

DATE

4. The Responsible Party providing evidence of oil spill financial responsibility in the form of Self-Insurance is:

__________________________________COMPANY LEGAL NAME		_________________________________BOEM 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

5. The undersigned certifies on behalf of the Responsible Party that the requirements set forth in 30 CFR Part 553 and specifically §§ 553.21 through 553.28 have been met.

The undersigned further agrees that the Responsible Party, pursuant to the requirements of 30 CFR 553.15, will notify the BOEM oil spill financial responsibility program in the event the Responsible Party is no longer able to maintain evidence of oil spill financial responsibility as a Self-Insurer in the amounts stated in section 2 above.

FORM BOEM-1018 (Month/Year) PAGE 1 OF 2

Previous Editions are Obsolete.

6. The Responsible Party, as Self-Insurer, acting through the Designated Applicant must, no later than the first calendar day of the fifth month after the close of your fiscal year, submit either a renewal of this Self-Insurance or other acceptable evidence of financial responsibility.

_______________________________________ NAME OF AUTHORIZED REPRESENTATIVE OF RESPONSIBLE PARTY	_______________________________________ SIGNATURE
_______________________________________ TITLE OF AUTHORIZED REPRESENTATIVE OF RESPONSIBLE PARTY	_______________________________________ DATE

_{7. The Self-Insurer’s U.S. Agent for Service of Process is:}

__________________________________ NAME		_________________________________BOEM COMPANY NUMBER
_________________________________________________________________________________________________________ADDRESS
__________________________________CITY	____________________________STATE		________________________ZIP CODE
___________________________________AREA CODE AND TELEPHONE NUMBER	____________________________AREA CODE AND FAX NUMBER		________________________E-MAIL ADDRESS

8. In witness whereof, the Designated Applicant and the Self-Insurer have executed this instrument on the __________ day of ____________, __________.

MONTH YEAR

_{Designated Applicant for the Responsible Parties named herein:}

SIGNATURE of authorized representative OF DEsignated APPLICANT

NAME of authorized representative OF DEsignated APPLICANT

TITLE OF authorized representative OF DEsignated APPLICANT

FORM BOEM-1018 (Month/Year) PAGE 2 OF 2

Previous Editions are Obsolete.