Insurance Certificate

Status: Original and derived artifacts are available for this document.

Download: pdf

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

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, see 33 U.S.C. §§ 2701-2720
(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
DEDUCTIBLE OR EXCESS AMOUNT

UPPER LIMIT OF
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 $
the amount of $

3. This coverage is effective:

at
DATE

at

million in excess of
million.
and expires:

Central Standard Time

DATE

.

Central Standard Time

The insurance coverage evidenced by this Insurance Certificate will be applicable only in relation to each
incident (as defined by 33 U.S.C. § 2701(14)), first occurring on or after the effective date of this
Insurance Certificate and on or before the termination date of this Insurance Certificate, and will be
applicable only in relation to each incident giving rise to claims under the Act. Under no circumstances
will more than one insurance certificate apply to each incident.
4. The named Insurer(s) may at any time cancel this Insurance Certificate in accordance with the Act and
its implementing regulations 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 any Responsible
Party and to the Bureau of Ocean Energy Management (BOEM) oil spill financial responsibility program.
The instrument will remain in force until the earlier of either the expiration date or the following: (1) thirty
calendar days after BOEM and the Designated Applicant receive from the named insurer a notification of
intent to terminate this Insurance Certificate; (2) BOEM receives other acceptable OSFR evidence from
the Designated Applicant; or (3) all the covered offshore facilities to which this Insurance Certificate
applies have been permanently and appropriately abandoned either in compliance with 30 CFR part 250
or the equivalent state requirements. The undersigned agree(s) that any termination of this Insurance
Certificate will not affect the liability of the named Insurer(s) for any claims that arise from an incident that
first occurs on or after the effective date of this Insurance Certificate and on or before the effective date
FORM BOEM-1019 (Month 202#). Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this collection of information while the renewal
submission is pending with OMB.

Page 1 of 7

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

of the termination of this Insurance Certificate.
5. The named Insurer(s) agree(s) that any suit or claim, for which the Responsible Party(ies) that are
identified in form(s) BOEM-1017 (on file or attached) may be liable under the Act, may be brought directly
against the named Insurer(s) 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. In any such suit or claim brought against the named Insurer(s),
Insurers’ obligations under the Act and its implementing regulations arising from this Insurance Certificate
will be limited to the amount of insurance coverage identified in this instrument.
6. The undersigned further agree(s) that in defending a claim brought against the Insurer(s), the Insurer(s)
may only invoke all rights and defenses which would be available to the Responsible Party under the
Act and the defense that the incident was caused by the willful misconduct of the Responsible Party.
7. The undersigned Responsible Party further agrees, pursuant to the requirements of 30 CFR 553.15,
it will notify the BOEM oil spill financial responsibility program in the event that the Responsible Party
is no longer able to maintain evidence of oil spill financial responsibility to the extent stated in section
2 above.
8. Any changes or modifications reflected in this Insurance Certificate (Form BOEM-1019) apply prospectively only
and do not affect the validity, applicability, or effect of any previous version(s) of this Insurance Certificate that a
named Insurer or Responsible Party may have signed and do not affect claims that the Department of the
Interior or other federal government agencies or entities may have against a named Insurer or Responsible
Party based on any previous version(s) of the Insurance Certificate that a named Insurer or Responsible Party
may have signed.
9. In the event of any conflict or inconsistency between the following: (1) Form BOEM-1019; and (2) the Act and
the Act’s applicable promulgated regulations; the applicable provisions of the Act and promulgated regulations
will prevail.
10. The Designated Applicant must, no later than the first calendar day of the fifth month after the close of
the named Insurer’s fiscal year or expiration if earlier, submit either a renewal of this insurance or other
acceptable evidence of financial responsibility.
11. Insurance agent or broker for this Insurance Certificate:
COMPANY NAME

BOEM COMPANY NUMBER

ADDRESS
CITY
(
)
AREA CODE and TELEPHONE NUMBER

STATE
(
)
AREA CODE and FAX NUMBER

COUNTRY (If not U.S.A.)

ZIP CODE

E-MAIL ADDRESS

FORM BOEM-1019 (Month 202#). Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this collection of information while the renewal
submission is pending with OMB.

Page 2 of 7

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

12. 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

13. 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

14. The named Insurers designate the following U.S. Agent for Service of Process for this Insurance
Certificate:
NAME

BOEM COMPANY NUMBER

ADDRESS
CITY
(
)
AREA CODE and TELEPHONE NUMBER

STATE
(
)
AREA CODE and FAX NUMBER

ZIP CODE
E-MAIL ADDRESS

FORM BOEM-1019 (Month 202#). Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this collection of information while the renewal
submission is pending with OMB.

Page 3 of 7

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

15. 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

FORM BOEM-1019 (Month 202#). Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this collection of information while the renewal
submission is pending with OMB.

Page 4 of 7

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

16. The following named Insurers hereby certify their participation.
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
If additional space is required, additional copies of this page may be attached as continuation pages.

FORM BOEM-1019 (Month 202#). Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this collection of information while the renewal submission is pending with OMB.

Page 5 of 7

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

17. The following named Insurers hereby certify their participation (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 202#). Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this collection of information while the renewal submission is pending with OMB.

Page 6 of 7

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

OMB Control No.: 1010-0106
Expiration Date: 00/00/202#

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 202#). Previous Editions are Obsolete.
In accordance with 5 CFR 1320.10, BOEM is authorized to continue sponsoring this collection of information while the renewal submission
is pending with OMB.

Page 7 of 7