Your Name:  

Business Address:  

City: State: Zip: Email:  

URL: Phone: FAX:  

List of Merchandise:

How will the Merchandise be packed: Boxes Crates Drums
Origin of Shipment:
Destination of Shipment:
Is the Merchandise being shipped in Containers? Yes No
Average value of one case or shipping package:
Maximum value of any one case or shipping package:
Maximum value of any one steamer at one time:
List total value of shipments anticipated annually by vessel:
List total value of shipments anticipated annually by aircraft:
List total value of shipments anticipated annually by parcel post:
Is any Merchandise shipped on deck? Yes No
Are foreign parcel post shipments to be covered? Yes No
If yes, what is the maximum value of any one parcel post package?
Are foreign aircraft shipments to be covered? Yes No
If yes, what is the maximum value of any one parcel post package?
Is duty on import shipments to be covered? Yes No
Is any bank to be named as a loss payee? Yes No

If yes, give full details:
 

Does this applicant now have an open policy? Yes No

If yes, with whom have you had coverage and for how long?
 

If no, how has insurance previously been placed?
 

Have you ever experienced a loss of shipment? Yes No

If yes, give full details:
 

Marine Premiums (Last 5 years):
   

Losses (Last 5 years):
   

Describe types of losses during past 5 years: