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CARGO INSURANCE APPLICATION

Applicant: *
Phone: * Fax:
E-Mail:    
Address: *
City: * State: *
Zip Code: *    
Contact:
# of Years in Business:
Annual Gross Sales: $

Annual Values Insured: (these figures must include all shipments of which the client is responsible for the insurance, for example inbound shipments on an FOB basis, outbound shipments on a CIF basis):

Import: $ Export: $
Domestic Truck: $ Domestic Courier (UPS Etc) $
Description of Merchandise:
Countries Shipped From & To:
Description of Merchandise:
? Domestic Only: YES    NO    
Valuation:
Domestic Only: YES    NO    
(1)Invoice Value + Freight + 10%
(2)Invoice Value
(3)Invoice Value + Freight
For Imported Shipments, Do You Wish to Insure Duty? YES    NO    
Maximum Shipment Values: (These figures should be the high dollar amount for an individual shipment):
Per Vessel: $ Per Aircraft: $
Domestic Truck: $ Domestic Courier: $
Average Shipment Values: (These figures should be the average dollar amount for an individual shipment):
Per Vessel: $ Per Aircraft: $
Domestic Truck: $ Domestic Courier: $
Policy Limits (These figures should be the per shipment limits the client wants on the policy):
Per Vessel: $ Per Aircraft: $
Domestic Truck: $ Domestic Courier: $
Type of Coverage Required:
All Risk    FPA    War    
Is Warehouse Storage Required(Transit coverage ends once goods have been signed for at warehouse of destination, this coverage extends the insurance to cover goods stored in the warehouse):
YES    NO    
If yes, the Average $ Amount Stored in the Warehouse at any one time:
$
Maximum $ Amount Stored in the Warehouse at any one time:
$
Current Insurance Carrier:
Premium paid:

Loss History:

  Paid Pending Descript.
3rd full year prior $ $
2nd full year prior $ $
1st full year prior $ $
 
        


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