Form BOEM-1019 "Insurance Certificate"

What Is Form BOEM-1019?

This is a legal form that was released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement on January 1, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest available edition released by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BOEM-1019 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Interior - Bureau of Safety and Environmental Enforcement.

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Download Form BOEM-1019 "Insurance Certificate"

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U.S. Department of the Interior
OMB Control No.: 1010-0106
Bureau of Ocean Energy Management
Expiration Date: 01/31/2020
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, 33 U.S.C. §§ 2701-2672 (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
UPPER LIMIT OF
DEDUCTIBLE OR EXCESS AMOUNT
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 $
million in excess of the amount of
of $
million.
__________
3. This coverage is effective:
at
and expires:
DATE
DATE
Central Standard Time
at
.
Central Standard Time
4. The Insurer may at any time cancel this insurance certificate 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 all
Responsible Parties and to the BOEM oil spill financial responsibility program by certified mail. This instrument will
remain in force and the undersigned will remain liable until the expiration date or until the earlier of (1) thirty
calendar days after BOEM and the Designated Applicant receive a notification of your intent to cancel this
insurance certificate; (2) BOEM receives other acceptable OSFR evidence from the Designated Applicant; or (3) all
the COFs to which this Insurance Certificate applies have been permanently abandoned either in compliance with
30 CFR part 250 or the equivalent state requirements. The undersigned agrees that any termination of this
Insurance Certificate will not affect the liability of the Insurer for any claims that arise from an incident (i.e., oil
discharge or substantial threat of the discharge of oil) that occurs on or before the effective date of termination of
this Insurance Certificate.
5. The named Insurers agree that any suit or claim for which the Responsible Parties identified in form(s) BOEM-1017,
on file or attached, represented by the aforementioned Designated Applicant may be liable under Title I of the Act
may be brought directly against the named Insurers for claims up to the amount of insurance coverage asserted 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.
6. The undersigned further agrees not to use any defense except those that would be available to a Responsible Party
for whom the insurance was provided or that the incident leading to the claim for removal costs or damages was
caused by willful misconduct of a Responsible Party covered by this insurance.
FORM BOEM-1019 (January 2017)
PAGE 1 OF 6
Previous Editions are Obsolete.
U.S. Department of the Interior
OMB Control No.: 1010-0106
Bureau of Ocean Energy Management
Expiration Date: 01/31/2020
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, 33 U.S.C. §§ 2701-2672 (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
UPPER LIMIT OF
DEDUCTIBLE OR EXCESS AMOUNT
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 $
million in excess of the amount of
of $
million.
__________
3. This coverage is effective:
at
and expires:
DATE
DATE
Central Standard Time
at
.
Central Standard Time
4. The Insurer may at any time cancel this insurance certificate 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 all
Responsible Parties and to the BOEM oil spill financial responsibility program by certified mail. This instrument will
remain in force and the undersigned will remain liable until the expiration date or until the earlier of (1) thirty
calendar days after BOEM and the Designated Applicant receive a notification of your intent to cancel this
insurance certificate; (2) BOEM receives other acceptable OSFR evidence from the Designated Applicant; or (3) all
the COFs to which this Insurance Certificate applies have been permanently abandoned either in compliance with
30 CFR part 250 or the equivalent state requirements. The undersigned agrees that any termination of this
Insurance Certificate will not affect the liability of the Insurer for any claims that arise from an incident (i.e., oil
discharge or substantial threat of the discharge of oil) that occurs on or before the effective date of termination of
this Insurance Certificate.
5. The named Insurers agree that any suit or claim for which the Responsible Parties identified in form(s) BOEM-1017,
on file or attached, represented by the aforementioned Designated Applicant may be liable under Title I of the Act
may be brought directly against the named Insurers for claims up to the amount of insurance coverage asserted 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.
6. The undersigned further agrees not to use any defense except those that would be available to a Responsible Party
for whom the insurance was provided or that the incident leading to the claim for removal costs or damages was
caused by willful misconduct of a Responsible Party covered by this insurance.
FORM BOEM-1019 (January 2017)
PAGE 1 OF 6
Previous Editions are Obsolete.
7. The undersigned Responsible Party further agrees, pursuant to the requirements of 30 CFR 553.15, to 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 to the extent stated in section 2 above.
8. The Designated Applicant must, no later than the first calendar day of the fifth month after the close of the Insurer’s
fiscal year or expiration if earlier, submit either a renewal of this insurance or other acceptable evidence of financial
responsibility.
9. Insurance agent or broker for this Insurance Certificate:
COMPANY NAME
BOEM COMPANY NUMBER
ADDRESS
CITY
STATE
COUNTRY (If not U.S.A.)
ZIP CODE
(
)
(
)
AREA CODE and TELEPHONE NUMBER
AREA CODE and FAX NUMBER
E-MAIL ADDRESS
10. 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
11.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
FORM BOEM-1019 (January 2017)
PAGE 2 OF 6
Previous Editions are Obsolete.
12. The named Insurers designate the following U.S. Agent for Service of Process for this Insurance
Certificate:
NAME
BOEM COMPANY NUMBER
ADDRESS
CITY
STATE
ZIP CODE
(
)
(
)
AREA CODE and TELEPHONE NUMBER
AREA CODE and FAX NUMBER
E-MAIL ADDRESS
13.
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
Named Insurers :
COMPANY NAME
ADDRESS
CITY
STATE
ZIP CODE
FORM BOEM-1019 (January 2017)
PAGE 3 OF 6
Previous Editions are Obsolete.
14. The following named Insurers hereby certify their participation on this.
INSURANCE
DATE OF
BOEM ID
QUOTA
NAME AND TITLE OF
INSURANCE
INSURER’S NAME
AUTHORIZED SIGNATURE
RATING
RATING
NUMBER
SHARE
BINDING OFFICIAL
RATING
SERVICE
(MM/YY)
SUBTOTAL OF
QUOTA
SH
AR
If additional space is required, additional copies of this page may be attached as continuation pages.
E
FORM BOEM-1019 (January 2017)
PAGE 4 OF 6
Previous Editions are Obsolete.
14. The following named Insurers hereby certify their participation on this (continued).
INSURANCE
DATE OF
BOEM ID
QUOTA
NAME AND TITLE OF BINDING
INSURANCE
INSURER’S NAME
AUTHORIZED SIGNATURE
RATING
RATING
NUMBER
SHARE
OFFICIAL
RATING
SERVICE
(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 (January 2017)
PAGE 5 Of 6
Previous Editions are Obsolete.
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