Form BOEM-1018 Self-Insurance Information

OMB Control No.: 1010-0106
Expiration Date: xx/xx/202x

U.S. Department of the Interior
Bureau of Ocean Energy Management

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

3. This coverage is effective:

UPPER LIMIT (MUST BE
COMPLETED)

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
___________________________________
CONTACT PERSON FOR CLAIMS

____________________________
STATE

________________________
ZIP CODE
________________________
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)
Previous Editions are Obsolete.

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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

_______________________________________

_______________________________________
DATE

TITLE OF AUTHORIZED REPRESENTATIVE OF
RESPONSIBLE PARTY

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

__________________________________
NAME

_________________________________
BOEM COMPANY NUMBER

_________________________________________________________________________________________________________
ADDRESS

8.

__________________________________
CITY

____________________________
STATE

________________________
ZIP CODE

___________________________________
AREA CODE AND TELEPHONE NUMBER

____________________________
AREA CODE AND FAX NUMBER

________________________
E-MAIL ADDRESS

Designated Applicant for Responsible Party (if different than Responsible Party identified in No. 6 above):

SIGNATURE OF AUTHORIZED REPRESENTATIVE OF DESIGNATED APPLICANT

NAME OF AUTHORIZED REPRESENTATIVE OF DESIGNATED APPLICANT

TITLE OF AUTHORIZED REPRESENTATIVE OF DESIGNATED APPLICANT

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

YEAR

FORM BOEM-1018 (Month Year)
Previous Editions are Obsolete.

PAGE 2 OF 3

U.S. Department of the Interior
Bureau of Ocean Energy Management

OMB Control No.:
1010-0106
Expiration
Date: xx/xx/2023

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)
Previous Editions are Obsolete.

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