Form BOEM-1018 Self-Insurance Information

U.S. Department of the Interior OMB Control No.: _1010-0106

_{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 3

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 3

Previous Editions are Obsolete.

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

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

_{PAPERWORK REDUCTION ACT STATEMENT}

BUREAU OF OCEAN ENERGY MANAGEMENT OIL POLLUTION ACT OF 1990

OIL SPILL FINANCIAL RESPONSIBILITY FOR OFFSHORE FACILITIES

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that the Bureau of

Ocean Energy Management (BOEM) collects this information to:

1. Provide a standard method for establishing eligibility for oil spill financial responsibility (OSFR) for offshore facilities;

2. Identify and maintain a record of those offshore facilities that have a potential oil spill liability;

3. Establish and maintain a continuous record, over the liability term specified in Title I of the Oil Pollution Act of 1990, of financial evidence and instruments established to pay claims for oil spill cleanup and damages resulting from operations conducted on offshore facilities and the transportation of oil from offshore platforms and wells;

4. Establish and maintain a continuous record of Responsible Parties, as defined in Title I of the Oil

Pollution Act of 1990, and their agents or Authorized Representatives for oil spill financial responsibility for offshore facilities; and

5. Establish and maintain a continuous record, over the liability term specified in Title I of the Oil Pollution Act of 1990, of persons to contact and U.S. Agents for Service of Process for claims associated with oil spills from offshore facilities.

The BOEM will routinely use the information to:

1. Ensure compliance of offshore lessees and owners and operators of offshore facilities with Title I of the Oil Pollution Act of 1990;

2 Establish eligibility of applicants for OSFR; and

3. Establish a reference source of names, addresses, and telephone numbers of Responsible Parties for offshore facilities and their Authorized Representatives and Guarantors for claims associated with oil pollution from designated offshore facilities.

Responses are mandatory (33 U.S.C. 2716). No confidential or proprietary information is required to be submitted. The BOEM considers oil spill financial responsibility demonstrations, including supporting audited financial statements, to be public information open for review under the Freedom of Information Act (5 U.S.C. 552).

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) Control Number. The public reporting burden for an application for certification of oil spill financial responsibility is listed below. The burden includes the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the application. The average burden for this form and required information that could comprise a submission is 1 hour.

Comments regarding the burden estimate or any other aspect of this form should be directed to the Information Collection Clearance Officer, Bureau of Ocean Energy Management, 45600 Woodland Road, Sterling, VA 20166.

FORM BOEM-1018 (Month/Year) PAGE 3 OF 3

Previous Editions are Obsolete.