Cargo Application for Importers and Exporters.
(Does not apply to Trucking Companies)
Please fill out the form, and submit it to InsureCargo. For additional information or if you have any questions, please call Sales at 714-427-5858 Ext. 218.
Contact Information
 
Name
Your relationship to the Insured Company
 
Phone Fax
Email
 
Insured Company Information
 
Company Name
Street Address 1
Address 2
City St/Province
Country Zip Code
Company Website
No. of years in business
Nature of the
Business
(Manufacturer, Distributor, Importer, Exporter, etc.)
 
Geographical Limits
 
  U.S. to World World to U.S. World to World
U.S. to U.S. Intra - Country Shipments (other than U.S.)
 
Valuation
 
  Invoice, including Charges, Plus Ocean Freight, Plus 10%
Other:
 
Commodity
 
Principal
Merchandise
to be Insured
 
Packing
 
Containerized % Door to Door
  Full Less than Full
   
Packing
(Describe in Detail)
 
Limits of Insurance
 
$ By Any One Vessel. $ By Any One Domestic Conveyance.
$ By Any One Vessel on Deck. $ By Any One Barge.
$ By Any One Aircraft. $ By Parcel Post (U.S. Mail).
$ By Any One Owned / Leased Vehicle. $ By Any One Package via Express Carrier (UPS, Fedex).
 
Insured Volume
 
Export Import Domestic
Past 12 Mos. $ $ $
Est. Next 12 Mos. $ $ $
Est. Avg. Value Per Shipment $ $ $
Percent by Conveyance

Air

Vsl

Air

Vsl

Air

Trk

 
Gross Annual Sales  $
 
Warehousing
 
Address Description * Limit Average
1
$
$
2
$
$
3
$
$
* Type of Construction, Burglary & Fire Protection, Age, and Square Footage.
 
Geography
 
Principal Countries to which Goods are Exported
(Indicate % involved)
Principal Countries from which Goods are Imported
(Indicate % involved)
 
Current/Expiring Policy Information
 
Current Insurer
Broker
Policy Expiration Date
Current Premium Rate % 
Est. Annual Premium $
Current Deductible $ Desired Deductible $
Loss Information
(3-Year history, Countries, Amount,
Description of Loss)
 
Remarks
 
 Comments
 
Source
 
How did you hear about InsureCargo ? If Other:
 
Submit
 


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