Annual Cargo Insurance: Quotation Form
Name of Insured
Address of Insured
Postcode:
Telephone:
Fax: 
What is your contact e-mail address?
Year Established


Limits

         
Limits on a CIF (Cost, Insurance & Freight) + 10% Basis
Maximum Any one vessel or Aircraft £        
Maximum any one Location £        

Methods of Transportation
  
Seafreight    
Airfreight    
Road Hauliers Vehicles    
Vehicles owned or operated by the Assured    
Rail    
Post    
       
Imports
          
a) Brief description of goods involved
b) Brief description of How Packed and Stowed
c) Breakdown of Imports by area of origin, estimated value and terms of purchase
Area Estimated Annual Value Ex-Works FOB/CFR CIF/CIP

Europe, Scandinavia

Turkey, Greece

USA, Canada, Australia

Far East

Middle East

Rest of the World*
       
Exports
          
a) Brief description of goods involved
b) Brief description of How Packed and Stowed
c) Breakdown of Imports by area of origin, estimated value and terms of purchase
Area Estimated Annual Value Ex-Works FOB/CFR CIF/CIP

Europe, Scandinavia

Turkey, Greece

USA, Canada, Australia

Far East

Middle East

Rest of the World*
   
* The following territories are excluded: Afghanistan, Angola, Cuba, Ethiopia, Iran, Iraq, Lebanon, Liberia, Libya, Myanmar, Nicaragua, Nigeria, North Korea, Rwanda, Sierra Leone, Somalia, Sudan, Syria, Uganda, Countries comprised by the former territories of USSR and Zimbabwe and any other country where their local legislation decrees insurance must be effected locally, unless specially declared and accepted by Underwriters prior to shipment.
 
Inland Transits
         
a) Brief description of goods involved
b) Brief description of How Packed and Stowed
c) Estimated Sales Turnover
UK £
Eire £
 
Storage
          
a) Maximum value in Store £
b) Address of Storage facility
c) Brief description of goods
 
 
 
Claims History
         
Has any claim been made against the proposer or any Partner, Director, Consultant or Employee, or are you aware of any circumstances that may give rise to a claim for:
loss or damage to goods?
If yes, please give details:  
Date
Brief details of each claim
Cost of claim
Estimated Outstanding
 
Insurance History
         
Date cover may be required    
Have you been previously insured?    
If yes, state name of the Insurer and renewal date:  
Has any application for this form of Insurance ever been declined or has such Insurance ever been cancelled or special terms imposed?
If so, please give full details:  
 
   
I/We hereby declare that the above statement and particulars are true and that I/we have not suppressed or mis-stated any material facts and I/we agree that this Declaration shall be the basis of the Contract between me/us and the Underwriters.

COMPLETING THIS FORM DOES NOT BIND THE PROPOSER TO COMPLETE THE INSURANCE