GOODS-IN-TRANSIT PROPOSAL FORM (SINGLE LOAD TRANSIT INSURANCE)

GOODS-IN-TRANSIT PROPOSAL FORM (SINGLE LOAD TRANSIT INSURANCE)

PLEASE COMPLETE THIS FORM IN BLOCK LETTERS
PROPOSERS NAME IN FULL
PROPOSERS ADDRESS
PROPOSERS BUSINESS OR OCCUPATION
TEL
FAX
EMAIL
google@google.com
State extent of Journey From:

MonthDayYear
Date
To

MonthDayYear
Date
State Date
(a) When Goods are to be dispatched:

MonthDayYear
Date
(b)When journey is to be completed

MonthDayYear
Date
Exact mode of Transit
Name and Address of Carrier
State full description of Goods
Are the Goods Carried at Owners or Carrier's Risk
Total Value of Goods
Greatest value of any one borned by the Insured
What excess is to be borned by the Insured
State how the Goods are packed
I hereby declare and warrant that the above questions are fully and truthfully answered, that I/We have not with-held or concealed any circumstance effecting the proposed Insurance and I/We agree that this declaration and the answers given above, and not any extraneous Knowledge or information possessed by the Company shall be the basic of the contract between me/us and the company and I/We agree to accept a policy subject to the conditions prescribed by the Company and expressed in the Policy.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

State Date