Marine Single Transit Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
ABN
Interested Party
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Insured Goods Details
Please indicate if goods to be insured are
Please Select
New
Secondhand
Frozen
Fresh
Chilled
Please provide details
Please indicate if the goods will be
Please Select
Packed
Unpacked
Please provide details
Will the Goods be shipped in fully enclosed shipping containers?
Please Select
Yes
No
If no, provide details of shipping
Please indicate if the goods to be insured are
Rows
Yes
No
Are over-height or over-width to fit into enclosed containers
Require special lifting apparatus for loading and unloading
Requires refrigerant if voyage exceeds 12 hours
Susceptible to rust, oxidisation or discoloration
Require storage within a specific temperature range
Fragile
Subject to an on deck bill of lading
Please provide details of special instructions for packers, shipping and forwarding agents and carriers for the safe carriage of goods marked
Voyage and Conveyances
Type of Conveyance
Please Select
Sea
Air
Date Transit Commences
-
Day
-
Month
Year
Date
Please provide details of conveyance (including vessel name, airline and flight number if applicable)
Transit from
Transit To
Port of discharge if not final destination
Will goods be transshipped?
Please Select
Yes
No
If yes, please provide details
Cover
Do you require ‘all risks’ cover as per institute for the goods?
Please Select
Yes
No
If no, please provide details of level of cover required
Do you require an excess (in addition to any compulsory excess which may apply)?
Please Select
Yes
No
If yes, please provide details
If no, please provide details
Sum Insured
Sum Insured
$
Does the sum insured represent CIF +10%
Please Select
Yes
No
Marine Loss History
For last 5 years
Claim #1
Insurer
Date of Loss
-
Month
-
Day
Year
Date
Details of Claim
Amount
$
Claim #2
Insurer
Date of Loss
-
Month
-
Day
Year
Date
Details of Claim
Amount
$
Claim #3
Insurer
Date of Loss
-
Month
-
Day
Year
Date
Details of Claim
Amount
$
Duty of Disclosure
Has the insured:
Rows
Yes or No
Ever had a claim refused or cancelled or declined or special conditions imposed on a policy in the last 5 years?
Yes
No
Suffered claims of any nature in the last 5 years?
Yes
No
Been convicted of, or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property in the last 5 years?
Yes
No
Been declared bankrupt and not discharged within the last 12 months?
Yes
No
Are there any exceptional circumstances relating to the risk to be insured that you have not already told us about and that you know or should know may affect the Insurer’s decision to accept the insurance?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
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