Both CPIX and the Applicant agree that the information provided herein by either party is offered and is to be kept in strict confidence.

* Required Fields

 

Company Name:   * Company Address: *
Company Structure:       Public           Private          Operator        Non-Operator
Company Contact:  * Telephone: * Email:	Position:  Fax: Website:

 

 

Years in Business:                       

 

Are all operations onshore?

                                 Yes              No

Are all operations within Canada?

                                 Yes              No
If no, please specify locations:       

 

Does your company conduct any operations other than oil and gas exploration, development, and/or production?

                                 Yes              No                     
If yes, please describe:                 

 

Fields / Areas of operations:         

 

 

 

Does your company have a health, safety, and environment program in place?
                                 Yes              No

 

Does your company hold a “Partnerships” Certificate of Recognition from Alberta Workplace Health and Safety?
                                 Yes              No
If yes, please provide certificate number:       

 

Are you interested in obtaining further information relating to Loss Management and do you wish to be contacted to specifically discuss how CPIX Risk Services can assist your company?
                                 Yes              No

 

Which of the following risk services are of interest for your company?

             Development of Safety / Environment Manual & Emergency Response Plans

             Risk Surveys / Loss Control Program Audit

             Facility Inspections

             Hazard Assessment / Task Analysis

             Health, Safety, & Environment Training / Coaching / Support

 

CO-INSUREDS – If required, under each policy type, please list any companies to be named as co-insureds as well the relationship to your company (e.g. affiliate, subsidiary, landlord, bank, joint venture partner)

 

Liability Coverage	Control of Well Coverage	Property Coverage

 

 

NEW APPLICANTS ONLY – Please provide a summary of your current coverages:

 

NEW APPLICANTS ONLY – Please provide a five-year loss history:

 

 

COMPREHENSIVE GENERAL LIABILITY COVERAGE

Limit Request(s):              $2 MM           $5 MM            $10 MM         $15 MM        $25 MM

Deductible Request(s):    $25,000         $50,000         $100,000

 

Average Daily Production (Please choose one unit type for oil and one unit type for gas)

            Oil       BOPD                                    Gas       MCFPD

            Oil       M³PD                                     Gas       M³PD

 

 

CONTROL OF WELL / OPERATORS EXTRA EXPENSE COVERAGE

 

NOTE: Coverage is excluded for extramural wells.  Extramural wells are:

a)       Wells in excess of 3,200 metres (10,500 feet) vertical depth.

b)       Wells having a Gross AFE in excess of $2,000,000 (drilled and cased).

c)       Critical Sour Wells.

d)       Wells located outside of Canada.

Does your company require coverage for any extramural wells?               Yes                    No

If yes, then please complete the supplementary Extramural Wells Report form (Appendix A).

This form must be completed and terms agreed prior to the inclusion of coverage for any extramural wells.

 

 

REPORTING WELL METRES

Measured Depth is the length of the well bore’s path. True Vertical Depth is the vertical depth of a well independent of the well bore’s path.  In the case of a vertical well, the measured depth equals the true vertical depth. Net Insurable Metres = Measured Depth x Insurable Interest Note: Insurable interest includes joint venture interests that your company has agreed to cover.

 

The vertical depth of a well determines the applicable depth band in which the well metres should be reported.  Net Insurable Metres are then reported in the applicable depth band.  For example, in the diagram above, consider if the true vertical depth of the well (length of line AB) is 1,500 metres and the measured depth (length of line YZ) is 2,100 metres.  If your company’s interest in this well is 90%, then 1,890 metres would be reported in the first depth band (0-1,525 m).

 

Limit Request(s):              $5 MM           $10 MM          $15 MM           $25 MM

Deductible Request(s):    $25,000         $50,000         $100,000

 

NET INSURABLE METRES FOR WELLS (Excludes extramural wells) – Please record estimated activity for the next 12 months
Depth Band	Exploratory Drilling* (Estimated Net Metres)	Development Drilling** (Estimated Net Metres)	Producing*** (Net Metres for Existing Wells)	Workover**** (Estimated Net Metres)
0-1,525 m
1,526 m – 2,275 m
2,276 m – 3,200 m
Gross Number of Wells:
Net Number of Wells:
Annual Drilling Budget:
*Exploratory wells are wells drilled either in search of new/undiscovered reserves or to extend the limits of a known pool.  These wells usually involve a high degree of risk.  They may also be referred to as "new pool wildcat" (NPW) wells. **Development wells are wells drilled in a field of proven territory in order to complete a pattern of production. ***Producing wells include shut-in, injection and disposal wells. ****Workover operation(s) are those operations, in a cased well bore, to recomplete, restore or rehabilitate, and/or to modify or replace well equipment which entails the removal of the well head.  Routine pump, motor or rod changes and tubing repairs in pumping oil wells are not considered to be workovers.

 

PROPERTY COVERAGE

Please provide a current Statement of Values for your company.  You may use the supplementary Statement of Values form (Appendix B) or refer to it as a guideline in providing us with the information we require.

Your company’s Statement of Values will determine the limit of your Property and/or Business Interruption policy.  The maximum limit per occurrence of this policy is the stated net replacement cost of the highest valued facility/equipment listed and, if applicable, the corresponding total business interruption value for that facility.

 

 

Deductible Request(s):    $25,000         $50,000         $100,000

Request for Boiler and Machinery Breakdown Coverage:     Yes               No

 

PROPERTY	NET VALUES
Facilities
Production/Contractor’s Equipment
Office Contents/EDP Equipment

 

Facilities include: Multi-well Batteries, Compressor sites, Gas Plants, or Pipelines (excluding gathering systems).

 

Production / Contractor's Equipment includes: single wells & equipment, gathering lines, rental and contractor's equipment.

 

BUSINESS INTERRUPTION	TOTAL INTERRUPTION VALUE
3 Month Indemnity Period
6 Month Indemnity Period
9 Month Indemnity Period
12 Month Indemnity Period

 

Please complete a Business Interruption Value Calculation Form for each facility requiring business interruption coverage.

 

Direct Business Interruption is for fully and / or partially owned facilities.  Contingent Business Interruption is for non-owned facilities; insured interest in the facility is 0%.  Refer to the Business Interruption Value Calculation Form (Appendix C) for details on calculating BI values.

 

Indemnity Period is the number of months that coverage is required for business interruption on a facility.

 

 

DATE                                                                                                    Name of Company Contact:

                                               

 

APPENDIX A – EXTRAMURAL WELLS REPORT

 

SECTION 1 – DEFINITIONS

EXTRAMURAL WELL:

A)      Wells in excess of 3,200 metres (10,500 feet) vertical depth.

B)      Wells having a Gross AFE in excess of $2,000,000 (drilled and cased).

C)      Critical Sour Wells (according to AEUB definition).

D)      Wells located outside Canada

 

CRITICAL SOUR WELL:

a)       Any well from which the maximum potential H₂S release rate is 0.01 cubic metres per second (m³/s) or greater and less than 0.1 m³/s, and which is located within 500 metres (m) of the corporate boundaries of an urban centre.

b)       Any well from which the maximum potential H₂S release rate is 0.1 m³/s or greater and less than 0.3 m³/s, and which is located within 1.5 kilometres (km) of the corporate boundaries of an urban centre.

c)       Any well from which the maximum potential H₂S release rate is 0.3 m³/s or greater and less than 2.0 m³/s, and which is located within 5 km of the corporate boundaries of an urban centre.

d)       Any well from which the maximum potential H₂S release rate is 2.0 m³/s or greater.

e)       Any other well which the AEUB classifies as a critical sour well having regard to the maximum potential H₂S release rate, the population density, the environment, the sensitivity of the area where the well would be located, and the expected complexities during drilling, completing, or servicing operations.

 

AREA I:

-        Canada South of 60 degrees North.

-        Includes the United States of America but excludes those States detailed under Area II.

 

AREA II:

-        Canada North of 60 degrees North, but South of the Arctic Circle.

-        Includes the following States: Alabama, Alaska, Colorado, Florida, Louisiana, Mississippi, Montana, New Mexico, Texas, Utah, and Wyoming.

 

SECTION 2 – NOTES TO DATA SHEET

• If you intend to provide coverage for Joint Venture Interests, please include the combined Total Working Interest required in the Total Insurable Net Metres column below.
• If the well is Non-Operated, please include the name of the Operator

 

APPENDIX A – EXTRAMURAL WELLS REPORT

 

SECTION 3 – DATA SHEET (Please record estimated activity for the next 12 months)

 

		WELL 1		WELL 2		WELL 3
Well Name
Area
LSD
AEUB Category
Operated or Non-Operated
Operator’s Name
Subscriber’s Working Interest (%)
Total Insurable Net Metres
Exploratory Drilling – Y/N
Development Drilling – Y/N
Producing/Shut-In – Y/N
Workover – Y/N
Oil or Gas
Total AFE
Total Vertical Depth (m)
Total Measured Depth (m)
Estimated H2S %
Drilling Contractor
Estimated Spud Date
Co-Insured(s)

DATE                                                                                                    Name of Company Contact:

 

 

APPENDIX B – STATEMENT OF VALUES

LSD	Property Name	Type of Facility	Total Gross Value	Company Percent (%)	Net Company Value	Net Monthly Business Interruption Value	Indemnity Period (Months)	Company BI Value
TOTALS

Production / Contractor’s Equipment Value:			DATE:       Name of Company Contact:
Office Contents Value:

 

APPENDIX C – BUSINESS INTERRUPTION VALUE CALCULATION FORM

 

Policy Period:
Property Name:
LSD:
Operator:
Company Ownership:

   

CALCULATION   MONTHLY VALUES Production Revenue: Less Royalties: Net Revenue:     Less Non-Continuing Expenses*: Business Interruption Value: Not including Depletion.     Add Depletion**: Include only if requesting Depletion Endorsement. Business Interruption Value: Including Depletion.   Indemnity Period (Months):         3     6       9     12   DATE:         Name of Company Contact:

*Non-Continuing Expenses are a function of production.  These are variable costs because they will not have to be paid in the event of a business interruption claim; therefore, they are deducted in the BI Calculation.  Non-Continuing Expenses include Depletion.  Other examples of Non-Continuing Expenses include temporary employees and power.  Non-Continuing Expenses are opposite of your fixed costs which must continue to be paid even in the event of a business interruption claim. **Depletion is depreciation.  It is the systematic writing off, over the useful life of the unit, of the cost of acquiring, exploring and developing the natural resources being produced.  To determine the depletion amount, compare the reserves you think your company will produce with the finding cost (exploration and development costs) of the resource, then deplete this amount evenly over the life of the reserve.  When producing, a company is able to recover its finding costs.  In the event of a business interruption claim, a company's ability to recover the finding cost is delayed as a result of being unable to produce.  When a company has recovered from a business interruption incident and resumes normal operations, it is then able to continue to recover the finding cost.  Please contact our office if you have further questions regarding depletion. Please be advised that the Boiler and Machinery Endorsement must be included in your Property policy in order for a business interruption claim resulting from a Boiler or Machinery breakdown to be valid.