Form Application for Open Cargo Policy


Application for Open Cargo Policy

Applicant's Name:

Mailing Address Line 1:

Mailing Address Line 2:

City & State:

Zip Code:

Business of Insured:

Description of Goods to be Covered:

Type of Packing:

If "Bags" selected, Type and Ply:

Container Service % Contemplated:

Please check Method of Container Service:

Terms of Coverage:

If "Other Terms" selected, please specify:

Desired Deductible Amount $:

Desired Deductible Percentage:

Current Deductible, if different than above:

Geographic Scope:

If "Other" selected, please specify:

Principal Trading Areas (Name Countries) and Terms of Sales:

Principal Trading Area 1

From:

Via (Port):

To:

Terms of Sale:

Estimated Annual Volume (Indicate % Insured):

Principal Trading Area 2

From:

Via (Port):

To:

Terms of Sale:

Estimated Annual Volume (Indicate % Insured):

Principal Trading Area 3

From:

Via (Port):

To:

Terms of Sale:

Estimated Annual Volume (Indicate % Insured):

Basis of Valuation: Invoice Cost plus Freight Plus %:

If Other, please specify,

Average Value Per Shipment:

Maximum Value Per Shipment:

Limits of Liability Required: Any One Vessel:

Limits of Liability Required: Aircraft:

Limits of Liability Required: Foreign Parcel Post/Fedex/UPS (Per Package):

Limits of Liability Required: Any One Barge/Tow:

Estimated Annual Volume of Shipments:

Annual Gross Sales:

Current Insurance Carrier:

Has Present Carrier Requested Replacement of Coverage/Given Notice of Cancellation?

If No Cargo Policy in Force, How Has Your Insurance Been Handled Up to Now:

If "Other" selected, please explain:

Marine Premium and Loss Experience for Past Five (5) Years:

Marine Premium and Loss Experience 1

Year:

Premium:

Paid Losses:

Outstanding Losses:

Recoveries:

Principal Cause of Loss:

# of Claims:

Marine Premium and Loss Experience 2

Year:

Premium:

Paid Losses:

Outstanding Losses:

Recoveries:

Principal Cause of Loss:

# of Claims:

Marine Premium and Loss Experience 3

Year:

Premium:

Paid Losses:

Outstanding Losses:

Recoveries:

Principal Cause of Loss:

# of Claims:

Marine Premium and Loss Experience 4

Year:

Premium:

Paid Losses:

Outstanding Losses:

Recoveries:

Principal Cause of Loss:

# of Claims:

Marine Premium and Loss Experience 5

Year:

Premium:

Paid Losses:

Outstanding Losses:

Recoveries:

Principal Cause of Loss:

# of Claims:

Does the above Premium include any Annual Warehouse Premium?

Additional Coverages to Be Included in Quotation:

If "Other" selected, please describe:

Description of Domestic Inland Transit Operations (If Coverage Requested:

Geographic Limits:

Average Value per Shipment:

Maximum Value per Shipment:

Limits Required:

Estimated Annual Volume:

Valuation:

Modes of Transit: Rail %:

Modes of Transit: Common Carrier %:

Modes of Transit: Owned Truck %:

Modes of Transit: Air %:

Describe Packing:

Shipment Security (Seals, Locks, Alarms, etc.):

Inland Transit Losses:

Description of Domestic/Foreign Warehouse/Processing Operations (If Coverage Requested):

Location (Name & Address) Average Monthly Value Maximum Value Limit

Unnamed Location Coverage Required?

Requested Limit:

Are Any of These Locations Owned and/or Operated by the Applicant?

Anticipated Attachment Date:

Producer:

Date of Application:

Address:

City & State:

Producer Code #: