PROPOSAL FOR MARINE CARGO INSURANCE

Assured Name

Nature of Business

Address

Tel

Fax

Email Address

example@example.com

Date of Birth

Date

Describe in detail the cargo proposed for insurance (enclose copies of the invoice or proforma invoice, or import license, or catalogs if available)

Describe the nature of packing

If containerized, state whether:

(iv) Package marks and numbers

(v) Invoice/Proforma invoice No.

Name of vessel

Voyage flight No

Port of loading

Port of discharge

Date of loading / Sailing; From:

Date

Date to

Date

Bill of lading airway bill No

iv Port of transshipment if any

v Estimated date of Arrival

Date

(Complete 5 (vi) and (vii) if you are applying for an open policy)

1 Principal countries from which the goods are imported: (indicate % of total coming from each country)

2

3

4

Modes of conveyance(s)

The basis of valuation: Amount of invoice + freight (%)

ii Amount declared for insurance GHC

(Complete 6 (iii) and (iv) if you are applying for an open policy)

Limit of insurance

By any one vessel GHC

By any one aircraft GHC

By any one year GHC

Please give the name(s) of insurer(s) for the past 3 years (Complete a separate line for each year)

(ii)Premium and losses experience for the past 3 years (Give full details of all losses and premiums paid in respect of marine-cargo insurance, losses paid and outstanding for the past 3 years. Complete a separate line for each year)

Institute cargo clauses

Institute bulk oil clauses

9 Remarks (Any additional information)

DECLARATION

It is the duty of the proposer to disclose all material facts relevant to the risk. A material fact is one that is likely to influence our judgment and acceptance of your proposal. If your proposal is a renewal, it should include any change in facts previously advised to us. If you are in any doubt about facts considered material, disclose them. Please note that failure to disclose a material fact or if any information provided proves to be incorrect, we may void your policy and decline to pay any claim. I/We declare that the statements and particulars made by me/us in this proposal are, to the best of my/our belief, complete and true and I/we agree that this proposal, together with any other information supplied by me/us, shall form the basis of the contract of insurance effected thereon.

I further declare and agree that if the statement and particulars above have been completed in the handwriting of any other person other than the undersigned, such person is deemed to be the representative of the proposer for the purpose of completing this proposal.

Signing this proposal form does not bind the proposer or underwriter to complete this insurance.

Date

Signature

Agent Broker

PROPOSAL FOR MARINE CARGO INSURANCE

(Complete 4: (iv) and (v) if you are applying for a voyage policy)