COMPREHENSIVE GENERAL LIABILITY ENERGY PROGRAM QUESTIONNAIRE

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1 BOWEN, MICLETTE & BRITT, INC. North Loop West, Suite #00 Houston, Texas 00 () 0-00 / fax: () 0- COMPREHENSIVE GENERAL LIABILITY ENERGY PROGRAM QUESTIONNAIRE. Name and address of Insured:. Description of operations: Annual Payroll: $ Number of Employees: Annual Receipts: Domestic: $ Foreign: $. Number of years in business: If new operations, outline principals experience:. Safety/Inspection Representative: Phone: Fax:. Are audited financial Statements available, if requested: Yes No If no, please explain:. Is Workers Compensation insurance purchased in compliance with the State Workers Comp Act? Yes No. Do you lease any employees: Yes No If yes, explain:. Are you: A. An operator? Yes No B. A landowner drawing ROYALTY INCOME or INTEREST? Yes No C. An INVESTOR owning a non-operating interest in wells? Yes No D. A PROMOTER selling drilling prospects to operators for a carried interest in the wells? Yes No E. A DEVELOPER who, as operator, contracts to have wells drilled and when completed, the well is turned over to others for operation? Yes No F. An OPERATOR owning working interest in wells who manages lease operations for his co-owners of the working interests? Yes No

Safety/Inspection Representative: Phone: Fax:. Are audited financial Statements available, if requested: Yes No If no, please explain:.

2 G. A lease OPERATOR by CONTRACT who does not have a working interest in the wells? Yes No. Is non-owned Automobile coverage desired? Yes No 0. Any wells or operations in or over water? Yes No If yes, give complete details:. Any Owned Watercraft? Yes No If yes, outline size, type, horsepower, and use: Size Type Hp Use. Any wells or operations inside city limits? Yes No If yes, describe:. Any storage tanks? Yes No If yes, are they properly dyked? Yes No Estimate Maximum Capacity:. Any interest in Pipelines (over ")? Yes No If yes, outline in complete details:. Has insurance been cancelled or non-renewed in past five years? Yes No If yes, explain:. Does Insured own or operate any rigs? Yes No If yes, give details including: Type/Value: Depth Capacity: Estimated number of wells to be drilled: types of drilling contracts normally used:. Please explain the following with respect to drilling/workover operations: Type of drilling contract(s) used: Turnkey Day Work Footage IADC API Other (attach copy) Name of drilling contractor(s):. How are servicing operations contracted? A. Master Service Agreement? Yes No If yes, attach copy B. Well Service Contract? Yes No If yes, attach copy C. Individual job order/purchase order? Yes No. Insurance required of contractors and subcontractors: A. What limits of insurance are required of contractors and subcontractors?

Yes No If yes, describe:. Any storage tanks? Yes No If yes, are they properly dyked? Yes No Estimate Maximum Capacity:. Any interest in Pipelines (over ")? Yes No If yes, outline in complete details:.

3 ) General Liability $ ) Automobile Liability $ ) Employer s Liability $ ) Other $ B. Do you require contractors and subcontractors to purchase the following? ) Comprehensive General Liability? Yes No ) Contractual Liability? Yes No ) Completed Operations? Yes No ) Coverage for explosion X? Yes No ) Coverage for blowout & Cratering E? Yes No ) Coverage for Underground Resources D? Yes No ) Coverage for Saline Contamination W? Yes No C. Are Certificates of Insurance required? Yes No If yes, are they kept on file? Yes No Where? D. Do you require Waiver of Subrogation from drillers and workover contractors? Yes No E. Do you require that you be an Additional Insured on contractor s/subcontractor s policies? Yes No F. Do you maintain an approved contractor list? Yes No 0. Are all well sites fenced, including pumpjacks, tank batteries, separators, etc. Yes No. Do you do site preparation? Yes No. Are there any secondary recovery operations? Yes No. Are there any HS gas operations? Yes No. What is the amount you expect to spend as operator on independent contractors for: A. Lease Work $ B. Workover $ C. Drilling $. Provide the following summary on your producing wells you operate: (Operated Production) # STATE COUNTY # of Wells Avg. Well Depth 0 Deepest Well

Yes No ) Coverage for Saline Contamination W? Yes No C. Are Certificates of Insurance required? Yes No If yes, are they kept on file? Yes No Where? D.

4 . Provide the following summary on wells you have a financial interest in, but are operated by others: (Non-Operated Production) # STATE / COUNTY 0 # of Wells Avg. Well Depth Deepest Well Avg. Financial Interest %. Provide the following information on wells you plan to drill in the policy period as an Operator: (Drilling as Operator) # STATE COUNTY TARGET DEPTH 0. Provide the following information on wells you expect to participate in as a financial interest, but will not operate: (Drilling as Non-Operator) # STATE/COUNTY TARGET DEPTH YOUR WORKING INTEREST % 0

Provide the following information on wells you plan to drill in the policy period as an Operator: (Drilling as Operator) # STATE COUNTY

5 Date: Signature:

2 nd Notice AHCCCS Insurance Requirements ACTION REQUIRED September 29, 2014 Page 1 of 5

2 nd Notice AHCCCS Insurance Requirements ACTION REQUIRED September 29, 2014 Page 1 of 5 Dear Providers and Staff: 2 nd Notice ACTION REQUIRED September 29, 2014 Page 1 of 5 We distributed a blast fax communication to you on July 16 explaining that effective October 1, 2013 AHCCCS updated