HEADQUARTERS

8202 Florence Avenue, Suite 200

Downey, CA 90240
Phone 562/861-0309
888/IIA-FONE
Fax 562/923-6354
CA License No. 0476540

MARINE CARGO INSURANCE APPLICATION

Applicant
Address
City State Zip
Contact Name Phone # Fax # E-Mail

Principal Trade & Business (brief description)

Number Of Years Engaged In This Trade Effective Date Requested For Insurance

1. List Specific Types of Commodities To Be Insured (Please Be Specific)

Commodity Origin Destination Annual Value % Air % Vessel
A
B
C
D
E
Total Annual Value of All Insured Shipments: $
Comments

2. Describe The Type/Method Of Packing For Each Commodity Listed Above

3. Name, Address and Telephone Number For The Arranging Of Inspections, Packing And
Pre-Shipment Surveys

4. Containerized
Are Goods Containerized? Yes No Partial
Who Packs The Container And Where?

Are Other Goods Consolidated With Insured Goods In The Same Container?
Location Where Container Is Unpacked.
5. Limits of Liability
A. Maximum Value Of A Shipping Package Or Unit $
B. Maximum Value Per Shipment
Steamer (Under Deck) $
Steamer (On Deck) $
Aircraft $
Mail $
Other $

6. Insuring Conditions
 HEADQUARTERS

8202 Florence Avenue, Suite 200

Downey, CA 90240
Phone 562/861-0309
888/IIA-FONE
Fax 562/923-6354
CA License No. 0476540

A. Coverage Requested
"All Risk"
FPA Other: ____________________________
B. Shipments Will Be Insured At Invoice Cost Plus Freight Prepaid Plus 10% Acceptable?
Yes No, Requested Valuation: ________
C. Other Insurance Coverages Requested:
Strikes, Riots and Civil Commotion Warehouse/Storage
Import Duty Domestic Transit
War Risks
Other: _____________________
7. Deductible
Should Quotation Be Offered With Deductible?
No
Yes $_____________ per Bill of Lading
8. Please Complete With The Latest Five Year Insurance Experience
Year Marine Prem. Total Amount Of All Losses Claimed Insuring Conditions

Briefly explain any claims and actions taken to prevent future losses

9. Cancellation
Has Your Marine Insurance Policy Ever Been Canceled?
No
Yes
If Yes, State Reason and Insurer:

10. General Comments Or Remarks (i.e., Principal Steamship Line or Airline Used; rates
desired; reason for change etc.):

Print Name of Applicant Signature of Applicant

Date