First name:
Last name:
Position:
Organization:
Nature of your business:
Street address:
City:
State/Province:
Zip/Postal code:
Country:
Work Phone:
FAX:
E-mail:	(required to process)
Type of insurance   coverage interested in:
Proposed Effective Date:
Proposed Expiration Date:

Description of Product/Commodity to be shipped:
Type into the text box below.

How will the Merchandise be packed:	Boxes Crates Drums
Quantity:	pcs/boxes
Weight:	lbs.
Size (L x W x H):	L x W x H
Transport by:	Air   Sea   Truck
Other Requirements:

Origin of Shipment:

Destination of Shipment:

Is the Merchandise being shipped in Containers?	Yes No
Average value of one case or shipping package:
Maximum value of any one case or shipping package:
Maximum value of any one steamer at one time:
List total value of shipments anticipated annually by vessel:
List total value of shipments anticipated annually by aircraft:
List total value of shipments anticipated annually by parcel post:
Is any Merchandise shipped on deck?	Yes No
Are foreign parcel post shipments to be covered?	Yes No
If yes, what is the maximum value of any one parcel post package?
Are foreign aircraft shipments to be covered?	Yes No
If yes, what is the maximum value of any one parcel post package?
Is duty on import shipments to be covered?	Yes No

Is any bank to be named as a loss payee?

Yes No