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Form Application for Open Cargo Policy

    Application for Open Cargo Policy

    Applicant's Name:

    Mailing Address Line 1:

    Mailing Address Line 2:

    City & State:

    Zip Code:

    Business of Insured:

    Description of Goods to be Covered:

    Type of Packing:

    If "Bags" selected, Type and Ply:

    Container Service % Contemplated:

    Please check Method of Container Service:

    Terms of Coverage:

    If "Other Terms" selected, please specify:

    Desired Deductible Amount $:

    Desired Deductible Percentage:

    Current Deductible, if different than above:

    Geographic Scope:

    If "Other" selected, please specify:

    Principal Trading Areas (Name Countries) and Terms of Sales:

    Principal Trading Area 1

    From:

    Via (Port):

    To:

    Terms of Sale:

    Estimated Annual Volume (Indicate % Insured):

    Principal Trading Area 2

    From:

    Via (Port):

    To:

    Terms of Sale:

    Estimated Annual Volume (Indicate % Insured):

    Principal Trading Area 3

    From:

    Via (Port):

    To:

    Terms of Sale:

    Estimated Annual Volume (Indicate % Insured):

    Basis of Valuation: Invoice Cost plus Freight Plus %:

    If Other, please specify,

    Average Value Per Shipment:

    Maximum Value Per Shipment:

    Limits of Liability Required: Any One Vessel:

    Limits of Liability Required: Aircraft:

    Limits of Liability Required: Foreign Parcel Post/Fedex/UPS (Per Package):

    Limits of Liability Required: Any One Barge/Tow:

    Estimated Annual Volume of Shipments:

    Annual Gross Sales:

    Current Insurance Carrier:

    Has Present Carrier Requested Replacement of Coverage/Given Notice of Cancellation?

    If No Cargo Policy in Force, How Has Your Insurance Been Handled Up to Now:

    If "Other" selected, please explain:

    Marine Premium and Loss Experience for Past Five (5) Years:

    Marine Premium and Loss Experience 1

    Year:

    Premium:

    Paid Losses:

    Outstanding Losses:

    Recoveries:

    Principal Cause of Loss:

    # of Claims:

    Marine Premium and Loss Experience 2

    Year:

    Premium:

    Paid Losses:

    Outstanding Losses:

    Recoveries:

    Principal Cause of Loss:

    # of Claims:

    Marine Premium and Loss Experience 3

    Year:

    Premium:

    Paid Losses:

    Outstanding Losses:

    Recoveries:

    Principal Cause of Loss:

    # of Claims:

    Marine Premium and Loss Experience 4

    Year:

    Premium:

    Paid Losses:

    Outstanding Losses:

    Recoveries:

    Principal Cause of Loss:

    # of Claims:

    Marine Premium and Loss Experience 5

    Year:

    Premium:

    Paid Losses:

    Outstanding Losses:

    Recoveries:

    Principal Cause of Loss:

    # of Claims:

    Does the above Premium include any Annual Warehouse Premium?

    Additional Coverages to Be Included in Quotation:

    If "Other" selected, please describe:

    Description of Domestic Inland Transit Operations (If Coverage Requested:

    Geographic Limits:

    Average Value per Shipment:

    Maximum Value per Shipment:

    Limits Required:

    Estimated Annual Volume:

    Valuation:

    Modes of Transit: Rail %:

    Modes of Transit: Common Carrier %:

    Modes of Transit: Owned Truck %:

    Modes of Transit: Air %:

    Describe Packing:

    Shipment Security (Seals, Locks, Alarms, etc.):

    Inland Transit Losses:

    Description of Domestic/Foreign Warehouse/Processing Operations (If Coverage Requested):

    Location (Name & Address)

    Average Monthly Value

    Maximum Value

    Limit

    Unnamed Location Coverage Required?

    Requested Limit:

    Are Any of These Locations Owned and/or Operated by the Applicant?

    Anticipated Attachment Date:

    Producer:

    Date of Application:

    Address:

    City & State:

    Producer Code #:

    Copyright by Capacity Marine. All rights reserved.

    Copyright by Capacity Marine. All rights reserved.