Energy Consultants ApplicationName First Last Contact PhoneContact Email Legal Entity NameDBAEntity TypeSelectIndividualCorporationPartnershipLimited Liability Company (LLC)Joint VentureMunicipalityProfessional AssociationTrustOtherYear Business StartedFEINWebsite Address Types Physical Location Address Mailing Address Primary Physical AddressFor physical office buildings or locations used by the company. If more than one location, provide the primary or headquarters. Street Address City State / Province / Region ZIP / Postal Code Mailing AddressMailing address only. Street Name and Number Town/City State ZIP Code Brief Description of OperationsWhat is your profession?Check all that apply. Construction Consultants Drilling Consultant Environmental Consultant Flowback Consultant Gatekeeper Geophysical/Geoscientist Health and Safety Services Landmen Logistics Consultant Mud Men/Mud Loggers Perforating/Completion Consultants Pipeline Consulting/Inspection/Construction Production Consulting Pumpers and Gaugers Reservoir Engineering Royalty Business Seismic Surveys Testing Consultant Water Consultants Well Completion Consultant Workover Consultant Other Please describe your profession:Leadership Relevant Years of ExperienceEstimated Annual Gross RevenueEstimated Annual PayrollNumber of Full-Time EmployeesNumber of Part-Time Employees Current Carrier (If Any)Inception Date Month Day Year Primary Type of Coverage RequestedSelectGeneral Liability OnlyGeneral Liability and Professional LiabilityDeductible RequiredSelect$2,500$5,000$10,000OtherHave you had any Claims or Circumstances in the past 5 years? Yes No Claims Overview Do you require Owned Auto Coverage?Vehicles owned by your company or primarily used for business use. Yes No If Yes - Do you have and will you maintain a minimum of $1mm (each and every) auto primary Coverage? Yes No How many automobiles do you have in your fleet? Do you need Hired and Non-Owned Auto on your General Liability?Hired and Non-Owned Auto coverage is liability protection for accidents involving vehicles your business uses but doesn’t own, like employee-owned or rented cars being driven for business purposes Yes No If yes - Will you have no more than 10 instances of Non-Owned Auto use and no more than 20 Hired Auto Instances during this policy period? Correct No, there will be more. Unsure How many instances of hired auto per year expected:Hired autos are vehicles your business leases, rents, or borrows for work—not ones it owns.How many instances of non-owned per year expected:Personal cars that your workers use for company business, which the business itself does not own, lease, rent, or borrow. Do you want to include Umbrella Coverage? Yes No Do you need Hired and Non-Owned Auto coverage in the Umbrella? Yes No If Yes - What is the Umbrella limit you require?Select$1mm xs $1mm$2mm xs $1mm$3mm xs $1mm$4mm xs $1mm$5mm xs $1mm$6mm xs $1mm$7mm xs $1mm$8mm xs $1mm$9mm xs $1mm$10mm xs $1mm$15mm xs $1mm$20mm xs $1mmOtherDo you require Employers Liability Cover in the Umbrella?Helps protect a business if an employee sues over a work-related injury or illness that is not fully covered by workers’ compensation. Yes No If Yes - Do you have and will you maintain a minimum of $1mm (each and every) Employers Liability primary coverage? Yes No Statement of FactDo you contract on anything other than a knock for knock basis?This often refers to the liability section in your MSA or other contractual agreements. Yes No Do you perform any hands-on work or direct manual tasks? Yes No Do you or do you plan to undertake or engage in any offshore work or activities? Yes No Do you undertake or perform any work, render services or engage in activities that do not solely relate to the oil and gas industry? Yes No Will you be undertaking or engaging in any work, services, or activities outside the USA? Yes No Do you subcontract work to others? Yes No Physical Office LocationTotal Occupied Square FeetHow much Business Property is owned by you?This includes Furniture/Fixtures/Equipment, Inventory, and Personal belongings.How much Tenant Improvement coverage is requested?Physical changes or additions made by a tenant to customize a rented space for their business needs, such as installing fixtures, flooring, walls, or equipment.SelectNot SureNone$5,000$10,000$25,000$50,000Over $50,000Is there an Additional Interest/Lienholder?SelectYesNoCentral Alarm connected to a monthly service:SelectYesNoCentral Fire connected to a monthly service:SelectYesNoIs the building sprinkled:SelectPartially SprinkledFully SprinkledNot Sprinkled Δ