Company Name
Date of Application
Street Address
City
State
Zip
Insurance Agency Name
Agent Name
Agent Email
Agent Phone
Safety Rep. Name
Safety Rep. Email
Safety Rep. Phone
Safety Rep. Mobile
Alt. Contact Name
Alt. Contact Email
Alt. Contact Phone
Alt. Contact Mobile
Accounting Name
Accounting Email
Accounting Phone
Accounting Mobile
Tax ID Number
Company Phone
Company Fax
Years in Business
Description of Operation
Total Number of Employees
Total Number of Offshore Employees
Number of Employees Offshore Any Given Time
Number of Office Employees Any Given Time
Number of Land-Based (non-office) Employees Any Given Time
Number of Office Employees That Visit Offshore Locations
(1) Year
(1) Total of Employees on 941 Report
(1) Total Office Employees on 941 Report
(1) Total Land-Based (non-office) Employees on 941 Report
(1) Total Offshore Employees on 941 Report
(2) Year
(2) Total of Employees on 941 Report
(2) Total Office Employees on 941 Report
(2) Total Land-Based (non-office) Employees on 941 Report
(2) Total Offshore Employees on 941 Report
(3) Year
(3) Total of Employees on 941 Report
(3) Total Office Employees on 941 Report
(3) Total Land-Based (non-office) Employees on 941 Report
(3) Total Offshore Employees on 941 Report
(4) Year
(4) Total of Employees on 941 Report
(4) Total Office Employees on 941 Report
(4) Total Land-Based (non-office) Employees on 941 Report
(4) Total Offshore Employees on 941 Report
Percentage of Employees on Fixed Platforms
Percentage of Employees on Offshore Vessels/Jackups/Barges
Percentage of Employees on Inland Water Way Vessels/Jackups/Barges
Percentage of Employees on Floating Platforms
Does your company have a formal safety program? (Yes/No)
Does your company perform pre-employment physicals? (Yes/No)
Any Helicopter Medical Evacuations in the past 5 years? (Yes/No - List details below)
(1) Date - MM/DD/YYYY
(1) Was it Work Related? (Yes/No)
(1) Description of Injury/Illness
(1) Cost of Flight
(2) Date - MM/DD/YYYY
(2) Was it Work Related? (Yes/No)
(2) Description of Injury/Illness
(2) Cost of Flight
(3) Date - MM/DD/YYYY
(3) Was it Work Related? (Yes/No)
(3) Description of Injury/Illness
(3) Cost of Flight
(4) Date - MM/DD/YYYY
(4) Was it Work Related? (Yes/No)
(4) Description of Injury/Illness
(4) Cost of Flight
(5) Date - MM/DD/YYYY
(5) Was it Work Related? (Yes/No)
(5) Description of Injury/Illness
(5) Cost of Flight
Signature
Title
Date
Email
Tel.
Acknowledgement: The undersigned acknowledges and agrees that Blu Cypress Solutions, LLC and Lloyd’s of London will rely upon the accuracy and completeness of the representations provided in this form. Any errors, omissions, or misrepresentations, whether intentional or unintentional, may impact the pricing and/or coverage under the insurance policy issued. Furthermore, the undersigned understands that Blu Cypress Solutions, LLC may, on behalf of itself and/or Lloyd’s of London, request additional information or data at any time during the quoting, binding, or post-binding process.
I acknowledge and agree.
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