Freight Services Questionnaire
Important Note:
The questions contained in this form are designed to give Insurers information regarding your business. It cannot always cover every aspect and it is your duty to disclose all material information to insurers that may affect the premium or conditions. This form can be completed with or by your Insurance Broker who will be able to assist you in a professional capacity.
1) General Information
Name of Broker:
Contact:
Address Line 1:
Address Line 2:
Phone Number:
Fax Number:
Email:
Name of insured:
Address Line 1:
Address Line 2:
Phone Number:
Fax Number:
Email:
Other Offices:
Year Formed:
Total Number of Employees:
Total Number of Directors/Partners:
Operations for which you require insurance:- (Please tick as appropriate)
Important Note:
If you require insurance for these operations you should complete the OPERATIONAL INFORMATION, INSURANCE HISTORY AND OTHER INFORMATION ( Excluding the General Information ) sections of the applicable Questionnaire.
Are you a member of any Trade Association, if so, please provide details:-
Please provide any background or general information regarding your organization:-
2) Operational Information
Important Note:
If you are not operating under BIFA, CMR, COGSA/Hague Visby, Warsaw Convention or under the conditions of FIATA then you must provide a copy of the Contract/Trading Conditions for Underwriter`s approval.
Please advise the percentages of your Traffic to/from or within the following areas:-
Please advise if you issue any of the following transport documents:
Important Note:
Please note you must provide copies of the documents you issue for Underwriter's approval prior to attachment of cover:
Please advise the percentages of your traffic for the following types/categories of cargo:-:
Additional details of high value cargo:
Do you own or operate any of the following:-
Important Note:
If yes for any of the above, you must provide full details on a separate sheet.
Please advise the numbers of staff employed in the following categories:-
Please provide turnover ( gross freight receipts) as follows:-
3) Insurance History
Can you please provide details of your Insurers and Broker during the last 4 years:-
Please provide details of paid and outstanding claims for the last 4 years:-
Please confirm the deductible(s) that were applicable during the last 4 years:-
What deductible and limit do you require:-
Please provide details of any claim which exceeded (or is likely to exceed) USD( or Euros) 15,000 (£10,000) or which accounts for more than 25% of the total claims in any one year:-
4) Other Information
Please provide below any other information that may be material to the insurers (please use additional sheets for this or any other answers):-
I confirm that this form has been completed accurately by the company or by its appointed insurance broker or advisor and that all material information has been given. Completion of this form is not binding on either party.
Company:
Position:
Signed:
(By typing your name, you are officially signing this form)
Date:
(If completed by an Insurance Broker or advisor please state)
Important Note:
If a quotation is put forward it will contain various Terms, Conditions and Exclusions. The Company strongly recommends you examine the quotation in conjunction with your Insurance Broker before acceptance.
Please attach any additional forms using the following fields
