Application - Blu Cypress Solutions

HeMEP Policy Application

Please be aware that Blu Cypress Solutions, LLC and Lloyd’s of London will rely upon the representations made on this form. Any mistakes that you make, whether accidental or intentional, may subsequently affect pricing and/or coverage under the policy of insurance bound.

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 Land-Based Employees

Total Number of Offshore Employees

Number of Employees Offshore at Any Given Time

Number of Office Employees That Visit Offshore Locations

Percentage of Employees on Fixed Platforms

Percentage of Employees on Offshore Vessels/Jackups/Barges

Percentage of Land-Based Employees (excluding office personnel)

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

Your Name

Title

Date

Signature

Tel.

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HeMEP Policy Application

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