Online Marine Insurance Form

MARINE CARGO Insurance Proposal Form

Intermediary Code Insurance Policy Number

INSURED INFORMATION

Name of Insured :

Nature of Insured’s Business Activity :

Address : City : Postal Code :

VAT No. : Tax office :

Telephone : FAX : E-mail :

COVERAGE DESIRED FOR

Imports Exports Inland Transits

TYPE OF POLICY REQUIRED

One Voyage / Transit Policy Open Cover Policy (annual) Block Policy (annual)

UNDERWRITING INFORMATION

Description of subject matter / merchandize / cargo to be insured :

Subject matter / merchandize / cargo proposed for insurance is:

New Used Reconditioned

Means of transportation / mode of shipment & proportion percentage for each :

Sea Road Air Rail Post Parcels

Courier Other (please specify)

Packing Details (i.e.drums, bundles, cartons / crates /bags e.t.c palletized / wrapped) :

Are containers used? Yes No If yes, state whether:

Full container load Less container load Reefer others

a) If full container load, who packs the containers? shipper carrier other

b) Where is the container destuffed? port of discharge your / consignee’s warehouse. If other, please specify.

Details of Voyages:

Estimated Annual Insurable Volume :

Frequency of Shipments per month :

Limits:

a) Limit per Location during transit :

b) Maximum value shipped (i.e. maximum value of the merchandize on any one Truck/Road Vehicle /Rail /Air / Ocean Going Vessel / Courier / Post Parcel :

Basis of Valuation :

INSURING TERMS & CONDITIONS

Institute Cargo Clauses A Institute Cargo Clauses B Institute Cargo Clauses C

Malicious Damage War risks Strikes Burglary Other

Will there be any transshipment? If yes, please give details:

Do you require storage cover at intermediate inland locations, originating ports (exports), and arrival ports (imports) e.t.c.? If yes, please mention:

a) Location (city/town/port) :

b) Number of days / weeks:

c) Maximum amount insured per location:

Are the shipments carried out by:

the insured’s own means third parties’ means (i.e. transportation companies)

If both the above are ticked, please mention the proportion percentage for each case.

Have you entered into a special contract with any Carrier restricting their Liability? Yes No

LOSS RECORD

Please mention below the losses for the last three years :

Period of Insurance : From To

IMPORTANT NOTICE

• It is your duty to answer all questions fully and to disclose all material facts to Underwriters. A material fact is one which may influence an Underwriter's judgement in the consideration of your proposal. If your proposal is a renewal, it is likely that any change in facts previously advised to Underwriters will be material and such changes should be highlighted. If you are in any doubt as to whether a fact is material you should consult your broker or disclose it.

• Failure to so inform us may invalidate this insurance or any claim made under it.

• The particulars provided by, and statements made by, or on behalf of the Applicant(s) contained in this application form and any other information submitted or made available by, or on behalf of the Applicant(s) are the basis for the proposed policy and will be considered as being incorporated into and constituting a part of the proposed policy.

DATA PROTECTION NOTICE

• The Underwriters will collect certain information about individuals within or connected to your company and any subsidiaries ("data subjects") in the course of considering your application and, if we issue a policy, in conducting our relationship with you. This information will be processed for the purpose of underwriting your insurance coverage, managing any policy issued, providing risk management advice and administering claims. We may pass the information to our reinsurers, legal advisers, loss adjusters, group companies or agents for these and other purposes. This may involve its transfer to countries which do not have data protection laws.

• By signing this proposal form you confirm the consent of the data subjects to the processing and transfer of information (including sensitive information) described in this notice, and that you have taken all steps necessary to inform them of our processing and your disclosure of information to us for the purposes described above. Without this consent and your confirmation of these matters, we would not be able to consider your application.

DECLARATION

• I/we hereby confirm that I am authorised to complete this Application Form on behalf of all parties entitled to coverage under this insurance.

• I/we declare that the statements and particulars contained in the proposal are true and that I/we have not misstated or suppressed any material facts.

• I/we undertake to inform Underwriters of any material alteration to these facts occurring before completion of the contract of insurance as well as during it.