Insurance Purchase Form
Wellhead Insurance
Company Name *
Your answer
Your Name *
Your answer
Date of Birth *
Address - Including Postal Code *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Are you currently insured with Intact *
Percentage of work done in field *
Description of Operations in Detail *
Any Welding? *
Length of Experience? *
Are Decisions made on site or is authority obtained? *
Responsible for any Maintenance? *
If yes to Maintenance, please describe
Your answer
Type and Cost of Work Subcontracted *
Your answer
Do you work with any tools, equipment, or computers? *
If "Yes" to above, please describe
Your answer
Describe qualifications, tickets, and training *
Your answer
Estimate of Annual Revenue *
Do you work in the US or other foreign country? *
Required Commercial General Liability Coverage *
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