Marine Annual Cargo 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
2 digit day, 2 digit month, 4 digit year
Date
Policy Due Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit 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 provide full details of subject matter to be insured
Will the subject matter be shipped in bulk?
Please Select
Yes
No
If yes, please provide details
For subject matter not shipped in bulk, indicate if they will be packed in the following
Please Select
Cartons
Crates
Bags
Drums
Bundles
Other- Provide details
Please indicate if subject matter to be insured is
Please Select
New
Secondhand
Frozen
Fresh
Chilled
Please advise if subject matter will be in fully enclosed shipping containers
Please Select
Yes
No
If no, please 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
Please provide details of countries you will import subject matter from and the percentage of your total imports for each country
Please provide details of all countries you will export subject matter to and the percentage of your total exports for each country
Do you require goods in transit cover within Australia / New Zealand?
Please Select
Yes
No
Do you require cover for voyages not beginning or ending in Australia or New Zealand?
Please Select
Yes
No
Conveyance
Imports
Sea
%
Air
%
Parcel Post
%
Exports
Sea
%
Air
%
Parcel Post
%
Transit within Aus/NZ
Sea
%
Air
%
Parcel Post
%
Valuation
Please advise how your goods are valued
Imports - CIF +10%
Please Select
Yes
No
If no, provide details
Exports - CIF +10%
Please Select
Yes
No
If no, provide details
Inland transit invoice value
Please Select
Yes
No
If no, provide details
Maximum Value of Goods
Rows
Imports
Exports
Inland Transit
Any one conveyance
Any one location
Method of Declaration
Annual Policy
Please Select
Value of Insured Goods
Sales Turnover
Open Cover
Please Select
Monthly
Each Shipment
Annual Amount Shipped
Rows
Imports
Exports
Local
Current Year
Previous Year
Marine Loss History
For last 5 years
Claim #1
Insurer
Date of Loss
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Details of Claim
Amount
$
Claim #2
Insurer
Date of Loss
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Details of Claim
Amount
$
Claim #3
Insurer
Date of Loss
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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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