Form Application Freight Services

Freight Services Questionnaire

Important Note:

The questions contained in this form are designed to give Insurers information regarding your business. It cannot always cover every aspect and it is your duty to disclose all material information to insurers that may affect the premium or conditions. This form can be completed with or by your Insurance Broker who will be able to assist you in a professional capacity.

1) General Information

Name of Broker:

Contact:

Address Line 1:

Address Line 2:

Phone Number:

Fax Number:

Email:

Name of insured:

Address Line 1:

Address Line 2:

Phone Number:

Fax Number:

Email:

Other Offices:

Year Formed:

Total Number of Employees:

Total Number of Directors/Partners:

Operations for which you require insurance:- (Please tick as appropriate)

  • Freight Services:
  • Container Operator:
  • Ship Agent:
  • Vessel/Slot Charterer/Operator:
  • Terminal Operator:
  • Port Authorities:

Important Note:

If you require insurance for these operations you should complete the OPERATIONAL INFORMATION, INSURANCE HISTORY AND OTHER INFORMATION ( Excluding the General Information ) sections of the applicable Questionnaire.

Are you a member of any Trade Association, if so, please provide details:-

Please provide any background or general information regarding your organization:-



2) Operational Information

Type % Conditions Attached
Freight Forwarder
As Agent
Freight Forwarder
As Principal
NVOCC
Road Carrier: Own
Sub-Contract
Rail Carrier: Own
Sub-Contract
Air Carrier: Own
Sub-Contract
Warehousekeeper: Own
As Agent
Other (Please Specify)

Important Note:

If you are not operating under BIFA, CMR, COGSA/Hague Visby, Warsaw Convention or under the conditions of FIATA then you must provide a copy of the Contract/Trading Conditions for Underwriter`s approval.

Please advise the percentages of your Traffic to/from or within the following areas:-

Area Road Rail Cont. (Sea) Non Cont. (Sea) Air
USA/Canada
Mexico
C/S America
Middle East
Europe
Italy
C.I.S.
India/Pakistan
China
Far East
Africa
Australasia

Please advise if you issue any of the following transport documents:

Type of Document YES/NO
Bill of Landing
Multimodal Transport Document
Seaway bill
Airway bill
Consignment Note
Freight-forwarder's bill

Important Note:

Please note you must provide copies of the documents you issue for Underwriter's approval prior to attachment of cover:

Please advise the percentages of your traffic for the following types/categories of cargo:-:

Type/Category %
Personal Effects
Wine or Beer
Spirits and other Alcoholic Beverages
Cigarettes and other Tobacco based products
Fur and leather or garment/items made from Leather/Fur
Clock watches and parts
Computer micro chips, Hi-fis, CD Players, etc.
Personal Computers and Game Consoles
Televisions
CD players, DVD players, CD's DVD's Tapes and Videos
Cellular or Mobile Telephones of any description
Temperature Controlled Cargo
Plants and/or cut flowers
Any other cargo of a high value (please give details)

Additional details of high value cargo:

Do you own or operate any of the following:-

Containers YES/NO
Trailers
Trucks/Vans
Rail Wagons
Tractor Units
Fork Lifts
Cranes
Warehouses
Depots

Important Note:

If yes for any of the above, you must provide full details on a separate sheet.

Please advise the numbers of staff employed in the following categories:-

Directors/Senior Management Number
Senior Technical
Clerical/Secretarial
Operational
Drivers
Warehousemen
Others (Please Specify)

Please provide turnover ( gross freight receipts) as follows:-

Time Period Gross Freight Receipts
Next 12 Months
Current Year
Current Year Minus One
Current Year Minus Two



3) Insurance History

Can you please provide details of your Insurers and Broker during the last 4 years:-

Time Period Broker Insurers
Current
Minus 1
Minus 2
Minus 3

Please provide details of paid and outstanding claims for the last 4 years:-

Time Period Paid O/S Total
Current
Minus 1
Minus 2
Minus 3

Please confirm the deductible(s) that were applicable during the last 4 years:-

Time Period Deductible
Current
Minus 1
Minus 2
Minus 3

What deductible and limit do you require:-

Deductible Limit

Please provide details of any claim which exceeded (or is likely to exceed) USD( or Euros) 15,000 (£10,000) or which accounts for more than 25% of the total claims in any one year:-



4) Other Information

Please provide below any other information that may be material to the insurers (please use additional sheets for this or any other answers):-

I confirm that this form has been completed accurately by the company or by its appointed insurance broker or advisor and that all material information has been given. Completion of this form is not binding on either party.

Company:

Position:

Signed:

(By typing your name, you are officially signing this form)

Date:

(If completed by an Insurance Broker or advisor please state)

Important Note:

If a quotation is put forward it will contain various Terms, Conditions and Exclusions. The Company strongly recommends you examine the quotation in conjunction with your Insurance Broker before acceptance.

Please attach any additional forms using the following fields