MARINE CARGO
INSURANCE PROPOSAL FORM
SECTION I
Full Name of
Proposer: ______________________________________________________
Office / Contact Address:_____________________________________________________
_________________________________________________________________________
Telephone No (s):___________________________ Fax:
___________________________
Email: ___________________________________ Web site: ________________________
Means of Identification: _____________________________
ID No: ___________________
Nature of Business (Give full
details)____________________________________________
________________________________________________________________________
How long have you been in Business __________________________________________
SECTION II (Please write or tick where applicable)
Nature of Cargo carried:
_____________________________________________________
_________________________________________________________________________
What is your experience in the shipment of this kind
of goods?:_______________________
Type of Packing: Cartons Wooden Cases Bundles Bulk Shipment
 |
Bags
Others, please specify: _____________________________________________________
Type of Cover: 
Open Cover Single Transit
 |
 |
Mode of Transit: Air Sea
Maximum Sum Insured Per Conveyance (Bottom Limit): __________________________
Expected Premium: N
_____________________Source of Funds:
__________________
Bankers: _________________________________________________________________
Voyage/Transit: From:
_______________________________________________________
To:
_________________________________________________________
Insurance Coverage Required
Institute Cargo Clauses (A)
Institute Cargo
Clauses (B)
Institute Cargo Clauses (C)
Others, please specify:
_______________________________________________________
_________________________________________________________________________
Has any Insurer declined or cancelled your business or imposed special
terms?
Yes No
If yes, give details:
__________________________________________________________
_________________________________________________________________________
DECLARATION: I / We agree that:
a) The information supplied in this proposal is true and complete and that I
/We have not
concealed, misrepresented or misstated any
material fact.
b) This Proposal shall form the basis of my /
our contract with the Insurer.
c) Immediate notice
shall be given of any alteration in the circumstances described herein.
d) No insurance will be
in force until this Proposal has been accepted by the Insurer and premium paid.
_________________________ ___________________
Signature of
Proposer Date
|
|
Official Use Only
Client’s
Risk Category: _________________________________________________
Name of Officer:
____________________________________________________________________
Premium Rate: _____________________________________________________________________
Any Additional Information:___________________________________________________________
Signature ______________________________ Date _____________________________
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