Form BOEM-1019 Insurance Certificate

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

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

_{INSURANCE CERTIFICATE}

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. Designated Applicant:

COMPANY LEGAL NAME BOEM COMPANY NUMBER

2. The amount of insurance coverage established by the named Insurers as evidence of oil spill financial responsibility (OSFR) for the Responsible Parties, identified in form(s) BOEM-1017 on file or attached, (hereafter the Insured), as represented by the Designated Applicant, in compliance with the Oil Pollution Act of 1990, as amended, 33 U.S.C. §§ 2701-2672 (hereafter the Act) and with Title 30 Code of Federal Regulations (CFR), part 553, 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

of $ __________ million.

3. This coverage is effective: at and expires:

DATE Central Standard Time DATE

at .

Central Standard Time

4. The Insurer may at any time cancel this insurance certificate by written notice of intent to cancel sent by certified mail to the Designated Applicant with copies (plainly indicating the original notice was sent by certified mail) to all Responsible Parties and to the BOEM oil spill financial responsibility program by certified mail. This instrument will remain in force and the undersigned will remain liable until the expiration date or until the earlier of (1) thirty calendar days after BOEM and the Designated Applicant receive a notification of your intent to cancel this insurance certificate; (2) BOEM receives other acceptable OSFR evidence from the Designated Applicant; or (3) all the COFs to which this Insurance Certificate applies have been permanently abandoned either in compliance with 30 CFR part 250 or the equivalent state requirements. The undersigned agrees that any termination of this Insurance Certificate will not affect the liability of the Insurer for any claims that arise from an incident (i.e., oil discharge or substantial threat of the discharge of oil) that occurs on or before the effective date of termination of this Insurance Certificate.

5. The named Insurers agree that any suit or claim for which the Responsible Parties identified in form(s) BOEM-1017, on file or attached, represented by the aforementioned Designated Applicant may be liable under Title I of the Act may be brought directly against the named Insurers for claims up to the amount of insurance coverage asserted by the U.S. government or by other claimants when a Responsible Party denies or fails to pay a claim on the basis of insolvency or a Responsible Party has petitioned for bankruptcy under Title 11 of the U.S. Code.

6. The undersigned further agrees not to use any defense except those that would be available to a Responsible Party for whom the insurance was provided or that the incident leading to the claim for removal costs or damages was caused by willful misconduct of a Responsible Party covered by this insurance.

FORM BOEM-1019 (Month/Year) PAGE 1 OF 6

Previous Editions are Obsolete.

7. The undersigned Responsible Party further agrees, pursuant to the requirements of 30 CFR 553.15, to 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 to the extent stated in section 2 above.

8. The Designated Applicant must, no later than the first calendar day of the fifth month after the close of the Insurer’s fiscal year or expiration if earlier, submit either a renewal of this insurance or other acceptable evidence of financial responsibility.

_{9. 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

10. As an Authorized Representative of the insurance agent or broker identified above, I certify that the information contained in this Insurance Certificate is accurate and correct, that quota shares total 100 percent for this Insurance Certificate, and that this Insurance Certificate and the named Insurers, complies with the requirements stated in 30 CFR 553.29. The identified insurance agent or broker agrees to maintain and provide to the Designated Applicant and 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.

NAME SIGNATURE

TITLE DATE

11.The named Insurers, listed below, certify that the Insured is insured by the named Insurers for the offshore facilities, as specified below, against liability for removal costs and damages to which the Insured could be subjected under Title I of the Oil Pollution Act and 30 CFR 553 within the insurance layer specified.

The following offshore facility coverage option has been selected:

□ General Option—All covered offshore facilities for which the named Designated Applicant serves in that

capacity.

□ Schedule Option— All covered offshore facilities on the Designated Applicant’s attached information form and schedule of properties forms, effective _____________________________________. DATE

FORM BOEM-1019 (Month/Year) PAGE 2 OF 6

Previous Editions are Obsolete.

12. 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

13. In witness whereof, the Designated Applicant for the Responsible Parties and the named Insurers 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

Named Insurers_:

COMPANY NAME

ADDRESS

CITY STATE ZIP CODE

FORM BOEM-1019 (Month/Year) PAGE 3 OF 6

Previous Editions are Obsolete.

14. The following named Insurers hereby certify their participation on this.

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 OF QUOTA SHARE

If additional space is required, additional copies of this page may be attached as continuation pages.

FORM BOEM-1019 (Month/Year) PAGE 4 OF 6

Previous Editions are Obsolete.

14. The following named Insurers hereby certify their participation on this (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%)

If additional space is required, additional copies of this page may be attached as continuation pages.

FORM BOEM-1019 (Month/Year) PAGE 5 Of 6

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 120 hours.

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-1019 (Month/Year) PAGE 6 OF 6 Previous Editions are Obsolete.