New Policy Application

Company Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Person:

Full Name*

First NameLast Name

Title*

Phone Number*

Format: (000) 000-0000.

E-mail*

example@example.com

How did you hear about us?*

Please Specify*

Number of Imports per year (Estimate)*

Average value of each import*

In USD

Maximum value of a import*

in USD

What is the Annual Value of shipments for the Prior Year?

What is the Annual Value of shipments for the Next fiscal year projection?

What are the gross annual sales of the company?

Are any of your suppliers connected with the Chinese Xinjiang Province?*

List all known manufacturers/vendors used to produce the goods to be covered by the Rezylient insurance:*

Do you have a risk management department/group that focuses on supply chain tracing? If so, please describe what efforts are made. *

Countries you import from*

What are your primary US ports of destination?

Types of goods imported*

List vendors used for supply chain tracing (risk management)*

Do you have a stated policy against forced labor?*

YesNo

Has any shipment received a UFLPA detention notice from the CBP in the past?*

IF yes , how was it resolved

Based on the number of shipments, what is the limit of insurance requested? Annual Aggregate requested? (the per shipment limit is based on invoice value and pays 40%)

Name and contact of Broker?

DO NOT SIGN UNTIL YOU HAVE READ THE CONTENT OF THIS APPLICATION AND THE APPLICABLE FRAUD WARNING(S).

I have reviewed the contents of this application and with my signature I declare to the best of my knowledge that all statments herein are true and no material facts have been suppressed or misstated. I am also aware that my operation may be inspected by the Insurance Company.

Applicant / Named Insured

First NameLast Name

Title

Signature

Please verify that you are human*

New Policy Application

Additional Information