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IMPORTANT NOTICE CONCERNING DISCLOSURE

It is your duty to disclose all material facts to Underwriters. A material fact is one that is likely to influence an Underwriter’s judgment and acceptance of your proposal. If your proposal is a renewal of an existing policy, it should also include any change in facts previously advised to Underwriters. If you are in any doubt as to whether or not

Details of Proposer

Name of Proposer(Required)

Address(Required)

Phone No(Required)

Email address(Required)

Trade or Business(Required)

Period of Insurance

From(Required)

To(Required)

Details of Shipment(s)

Details of Cargo to be insured(Required)

Is it new or second hand?(Required)

Yes

No

Method of Packing(Required)

Will cargo be containerised?(Required)

Yes

No

Will it be a full container load from door to door or groupage container service(Required)

Terms of sale(Required)

Insured Value any one consignment(Required)

Total Value of all your consignments on vessel(Required)

Voyage

Country(ies) where risk(s) normally commence(Required)

If from inland, type of transportation used(Required)

Will any transhipment be involved?

Yes

No

Please state the name of port/harbour(Required)

Will any “on deck” shipments be involved?(Required)

Please give details of vessel(s) if possible(Required)

Where does the risk terminate?(Required)

If inland, name of haulage contractor(s):(Required)

Other Information

Please state estimated annual value of imports(Required)

Conditions of insurance required:(Required)

Clause (A)

Clause (B)

Clause (C)

Claims Experience For Last 3 Years

Year

Number of Claims Paid

Amount of Claims Paid

Number of Claims Outstanding

Amount of Claims Outstanding

Present Insurers

Number of Claims Paid

Amount of Claims Paid

Number of Claims Outstanding

Amount of Claims Outstanding

Please supply full details of any major loses:

SIGNING THIS PROPOSAL DOES NOT BIND THE PROPOSER TO COMPLETE THIS INSURANCE.

Declaration(Required)

I agree to the privacy policy.

I/We declare that the statements and particulars in this proposal are true and that no material facts have
mis-stated or suppressed after enquiry. I agree that this proposal, together with any other information
supplied shall form the basis of any contract of insurance effected thereon. I/We undertake to inform the
Insurers of any material alteration to those facts occurring before the completion of the contract of insurance.