Shippers Interest Cargo Application
Company Information
Company Name
Date of Establishment
-
Month
-
Day
Year
Date
Company Contact Name
First Name
Last Name
Company Contact Email
example@example.com
Company Contact Phone
Please enter a valid phone number.
Company Website:
Has applicant changed name, merged, or been acquired in last 3 years?
Yes
No
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Shipped Values ($USD)
Estimated Insured Shipped Values for the next policy period:
Actual Insured Shipped Values (less 1 year):
Actual Insured Shipped Values (less 2 year):
Actual Insured Shipped Values (less 3 year):
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Interest
What percentage of your traffic does the following represent?
What percentage of your traffic does the following represent?
% Amount (must total 100%)
General Cargo
Electronic Equipment
Cell Phones
Haz-Mat / Dangerous Goods
Temperature Controlled Goods
Bulk Shipments
Tank Cargo
Machinery and Equipment
Project Cargo
Other
If Other is selected, please provide details below:
If the majority of goods shipped consist of Electronic Equipment, please provide full details. Ex: approximate percentage split between Cell phones / Computers / Televisions and the like.
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Trading Area
On a percentage basis advise the most common areas shipped to/from:
% Amount (must total 100%)
USA/Canada
Oceania
Africa
Asia
Central America
Middle East
South America
Europe
Caribbean
Methods of transport used:
% Amount (must total 100%)
International Ocean
International Air
Domestic Air
Domestic Road
Domestic Rail
What percentage of shipments are containerized?
% Amount (must total 100%)
FCL
LCL
What percentage of shipments are break bulk?
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Limit of Liability ($USD)
Maximum any one shipment of ocean conveyance:
Maximum any one shipment of air conveyance:
Maximum any one shipment of truck conveyance:
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Transportation
Do you operate owned trucks to move cargo?
Yes
No
If no, please provide an approximate breakdown between shipments in owned trucks and shipments on subcontracted trucks:
% Amount (must total 100%)
Owned
Subcontracted
Please provide details on the vetting procedure adhered to when selecting a Common Carrier (including the common carriers Motor Truck Cargo limit):
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5 YEARS LOSS HISTORY PAID & OUTSTANDING ($USD):
Has your insurance ever been cancelled or declined?
Yes
No
Are you aware of any pending claims or potential claims?
Yes
No
Please provide details on pending or potential claims:
Please upload loss history here:
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Agent Details
Agent Name
First Name
Last Name
Agent Phone
Please enter a valid phone number.
Agent Email
example@example.com
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Declaration
I declare that the statements and particulars in this application are true and that no material facts have been misstated or suppressed after enquiry. I agree that this proposal, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I undertake to inform the Insurers of any material alteration to those facts occurring before completion of the contract of insurance. A material fact is one which would influence the acceptance or assessment of the risk.
Signature of Applicant
Printed Name of Applicant
First Name
Last Name
Title/Position of Applicant
Current Date:
Submit
Should be Empty: