Freight Services Liability Application
Company Information
Company Name
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Contact Name:
First Name
Last Name
Company Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Company Contact Email
example@example.com
Company Website
Has applicant changed name, merged or been acquired in last 3 years?
Yes
No
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Years in Business
Number of Employees
Please confirm all activities for which insurance is required:
Rows
Required? (Y/N)
Freight Forwarder
Yes
No
Trucking
Yes
No
Tank Container Operations
Yes
No
N.V.O.C.C
Yes
No
Ship's Agent
Yes
No
Warehouse Operator
Yes
No
Air Cargo Agent
Yes
No
Customs Broker
Yes
No
Other
Yes
No
Please Specify "Other" if Selected
As a Customs Broker, what is the approximate number of entries handled in a 12-month period?
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Loss Prevention
Do you employ designated safety officers?
Yes
No
Please list Safety Officers here:
Do you have a loss prevention program in effect?
Yes
No
What training and education do you require for employees?
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Trading Area
On a percentage basis advise the most common areas shipped to/from:
Rows
% Amount
USA/Canada
India/Pakistan
Mexico
China
Central / South America
Far East
Middle East
South Africa
Africa
Europe
Caribbean
Australia
Method of Transport used
Rows
% Amount
International Ocean
International Air
Domestic Air
Domestic Road
Domestic Rail
What percentage of shipments are containerized?
What percentage of shipments are break bulk?
What percentage of traffic do you co-load with others?
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Insured Services
Please provide a % amount of Insured Services
Rows
% Amount
Freight Forwarder acting as Agent?
Freight Forwarder acting as Principal - by SEA
Freight Forwarder acting as Principal - by Air
Non-Vessel/Aircraft Operating Common Carrier (NVOCC/NAOCC)
Road Carrier - Owned Vehicles
Road Carrier - Sub Contracting
Air Carrier - Owned Vehicles
Air Carrier - Sub Contracting
Courier Service/Parcel Service
Customs House Broker/Agent/Clearing Agent
Warehouse Keepers - for goods stored at customer's request
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REVENUE
Rows
$USD Amount
Gross Freight Receipts (GFR)
Anticipated for 2025/2026
Actual for 2024/2025
Actual for 2023/2024
Please list annual fees or revenues generated from WAREHOUSING operations if not included in your total GFR’s above
Please list annual fees or revenues generated from CUSTOMS BROKERING operations if not included in your total GFR’s above
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Transportation
What percentage of your traffic does the following represent?
Rows
% Amount
Personal Effects
Computer/ Laptops
Artwork/Fine Arts
Liquor/Tobacco
Cell Phones
Antiques
Haz-Mat/ Dangerous Goods
Electronic Equipment
Temperature Controlled Goods
Bulk Shipments
Tank Cargo
Precious Jewellery/Stones
Used Goods
General Cargo
Project Cargo
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Maximum Values ($USD)
Estimate the maximum value at risk for the following:
Rows
$ Amount
Any one shipment of general cargo via ocean or air transportation:
Any one shipment of general cargo via vehicle or road transportation:
Any one shipment of personal effects or household goods:
Any one shipment of liquor or tobacco:
Any one shipment of temperature controlled goods:
Conditions of Business
Which of the following apply to your business? (Check all that apply)(Forward hard copies):
Own House Bill of Landing
House Airway Bill (International)
Domestic House Bill
Warehouse Receipt
Please Upload Copies of Checked Items Above
Browse Files
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Choose a file
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Please indicate your limit of liability ($USD) for the following:
Rows
$ Amount
Domestic Transit Limit:
Ocean Limit:
International Air Limit:
Do you require evidence of insurance from subcontractors?
Yes
No
Do you accept cargo for shipment on a "Value Declared" basis?
Yes
No
Principal Carrier(s) Used:
Current Insurance Details:
Rows
$ Amount
Policy No.
When does existing insurance policy expire?
Current policy limit of liability: CLL $USD
E&O $USD
Current policy deductible for: CLL $USD
E&O $USD
Has insurance ever been cancelled or declined?
Yes
No
Are you aware of any pending claims or potential claims?
Yes
No
Please provide details on potential or pending claims:
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Loss History
Please upload 5 years of loss history here:
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Drag and drop files here
Choose a file
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of
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Agent Info
Agent Name
First Name
Last Name
Agent Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Agent Email
example@example.com
Please Hit Submit on the Next Page
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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
Title/Position of Applicant
Current Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: