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Cargo Application


E-mail Address:
Company Name:
Phone Number:
Fax Number:
Address:
 
City:
State:
Zip:
Where did you hear about us?

The applicant is a...(check all that apply)

Manufacturer
Importer
Freight Forwarder
Other

Consumer
Broker
Purchasing Agent
Proposed effective date:
Description of Operations: (500 char max)
Brief Description of your level of shipping experience: (500 char max)
Does applicant have other divisions, subsidiaries, or affiliates?
Yes No
If "yes" please state name, location and whether or not they are to be insured hereunder, for each of them:

Insurance Background Information:
Present Underwriter:
Present Agent:
Estimated annual dollar volume of goods shipped:
Percent now insured by applicant:
%

1.
Last five years' experience:
Year Amount Insured Gross Marine Premium

# of Paid Marine Losses

Total Amount $  

# of Outstanding Marine Losses

Total Amount $  
2.
Year Amount Insured Gross Marine Premium

# of Paid Marine Losses

Total Amount $  

# of Outstanding Marine Losses

Total Amount $  
3.
Year Amount Insured Gross Marine Premium

# of Paid Marine Losses

Total Amount $  

# of Outstanding Marine Losses

Total Amount $  
4.
Year Amount Insured Gross Marine Premium

# of Paid Marine Losses

Total Amount $  

# of Outstanding Marine Losses

Total Amount $  
5.
Year Amount Insured Gross Marine Premium

# of Paid Marine Losses

Total Amount $  

# of Outstanding Marine Losses

Total Amount $  

Please fax a copy of company loss exhibit showing
breakdown of losses by amount and nature of loss, to us at 801.268.2674
Or, you can enter the information here: 500 char max
Goods to be insured (please describe fully) 500 char max
Packing please check all that Apply:

Steel Drums
Export Cartons

Fiber Drums
Export Bags
Solid Wooden Crates
Open Wooden Crates
Other (describe fully indicating materials, ply and stregnth of paper bags and cartons, use of skids, shrink-wrap, etc.)
Please provide details of specific safeguards against theft, pilferage, breakage, water damage, leakage or other damage:
Special Handling, equipment or containers:
Vented % Refrigerated %
Tank % Palletized/Unitized %
Open Top % Other %
If other please describe: (500 char max)

Estimated Percentage of Intermodal Containerized shipments:
Door to Door: %
Port to Port: %
Other: %
Who handles the intermodal containers?

Ocean Transit Info: (dollar amounts)
To From
Areas
 Steamer Air Freight Parcel Post
UK, Europe (Hamburg to Gibraltar)
Scandinavia
Europe Mediterranean
Greece, Turkey & North Africa
Africa (except as above), Red Sea
Near East
Persian Gulf, India, Bangladesh
Australia, New Zealand
Japan and Hong Kong
Far East (except as above)
West Indies and Hawaii
Mexico and Central America
North & East Coast of South America
West Coast of South America
What is the average value per shipping package? $
Per conveyance? $
What is the average value and weight per shipment by air?
$ weight
Is full value presently declared to the air carrier?
Yes No

How are the shipments transported from warehouse to port:
Domestically: Rail % Truck %
Other %
Foreign: Rail % Truck %
Other %
Type of Carrier:

Owned Vehicles %

Common Carrier %
Contract Carrier % Other %
Type of Bill of Lading:
Full Value Percent % Declared
Released Liability to Carriers $ per (pound or other)
Terms of Sale/Coverage Desired
Insuring Conditions
All Risks With Average Irrespective Percentage
Free of Particular Average Other (please explain)
Deductible Desired: $
Valuation:
CIR + %
Other (please explain below or fax copy of present clauses to us at 801.268.2674
Bill of Lading:(describe the bill of lading used for overseas shipments on various conveyances)
Vessel: Full Released $ per (pound or other)
Air: Full Released $ per (pound or other)
Truck: Full Released $ per (pound or other)
Rail: Full Released $ per (pound or other)
Limits:
On Deck: $ Barge: $
Under Deck: $ Aircraft $
Parcel Post $ Foreign Overland $ per-package
Any One Occurence (disaster limit) $
Are Special Policies (certificates) required? Yes No

Special Coverage Required: (other than MEC & South American Endorsement):
FOB/FAS Annual Dollar Volume
Automatic Warehouse Cover (Limits Required $)
Banker's Endorsment (name of Bank)
Contingency Insurance
Import Duty Endorsmement
Consolidation/Deconsolidation Cover
Exhibition (Location)
Domestic Inland Transit (Limits Required)
Other: Please Specify  
Has your marine insurance been cancelled or declined in the past 5 years:
Yes No
If "yes", please state reason for cancellation or declination:
Please add any information that would affectg underwriter consideration:

Information on your application will be
electronically encrypted for confidentiality
and security.


© Copyright 2012 Poulton Associates Inc.