Cargo Risks

The application form that follows is aimed to generate information regarding your operation’s exposure to risk and guide underwriters to provide the best package of cover and terms available. Please complete all relevant sections in full as accurately as possible as this may form a part of your future contract.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

	Vessel Information
Vessel Name
IMO
Built
Class
Flag
GRT/DWT

Please state the type of goods to be insured

Please state how the goods are packed

Value

USD

Please type of shipment method used

FROM

TO

Proposed date of departure

Date

Estimated date of arrival

Date

All Risks

Total Loss

For Annual or Open products, please confirm:

Policy limits, maximum value any one:

USD

Conveyance:

USD

Location and/or loss:

USD

Specified storage:

USD

Third Party vehicle:

USD

Own vehicle:

USD

Postal sending:

USD

Number

USD

Estimated value of sending for the next 12 months:

UKto UK:

USD

UK to/from Western Europe, Scandinavia and/or Channel Isles:

USD

UK to/from Eastern Europe (excluding former USSR and Yugoslavia):

USD

UK to/from USA, Canada, South Africa, New Zealand, Australia, Japan, Hong Kong, Taiwan, South Korea and/or Singapore:

USD

UK to/from Middle East (excluding Iran, Iraq, Libya and Yemen):

USD

Other voyages: (please state all countries involved below):

USD

If other, please state any countries involved below:

In the past 5 years, have any claims been made?

YesNo

If yes, please provide the following information:

	Date of Imitation	Total payment including losses	Total outstanding reserves	Open/Closed
Service Quality
Cleanliness
Responsiveness
Friendliness

If this is a new venture, please providedetails of industry experience:

I confirm that this form has been completed accurately and that all material information has been given. Completion of this form is not binding by either party.

Cargo Risks

INSURED INFORMATION

VESSEL INFORMATION

CARGO INFORMATION

VOYAGE INFORMATION

INSURANCE COVER REQUIRED

CLAIMS INFORMATION