Cargo Policy Application

General Information

PRODUCER INFORMATION

History on account

INSURED INFORMATION

Proposed Policy Effective Date:

LOSS HISTORY (PLEASE ATTACH FIVE YEAR HARD COPY LOSS RUNS IF AVAILABLE)

ANNUAL EXPOSURE INFORMATION

Company Gross Sales

Projected Shipment Values Inbound (Imports to US)

Projected Shipment Values Outbound (Exports from US)

Projected Shipment Values Domestic (US and Canada)

Projected Shipment Values (Intercompany Shipments)

LIMITS OF INSURANCE REQUESTED

Company Gross Sales

DEDUCTIBLE

What is the requested deductible?

VALUATION

*Standard Policy Valuation is Invoice Cost + Insurance + Freight + 10% (CIF + 10%)

Do you require different valuation?

COMMODITY INFORMATION

1. Please provide a breakdown of the goods and/or merchandise to be shipped (detailed description of goods and/or merchandise):

Are the goods and/or merchandise insured : Refrigeration Exposure: Do any commodities insured require refrigeration or temperature control?

2. What are the principal conveyance methods used (check all that apply)?

3. Are Imported or Exported shipments principally moved by ocean vessel?

4. Are Imported or Exported shipments principally moved by aircraft?

5. Who packs the shipments?

6. Are containers opened prior to destination?

7. Any special coverage requests or extensions?

GEOGRAPHIC SCOPE

1. What are the primary countries of origin and destination?

Do you require Domestic Transit coverage for shipments moving only within/between the Continental United States and/or Canada (this includes intercompany shipments)?

If you answered “Yes” to requiring domestic transit coverage above, please confirm: Breakdown of inland conveyance(s) used:

3. Does the insured move goods to/from or within Mexico and/or Central America?

4. Does the insured move goods to/from or within Africa?

5. Does the insured move goods only within the same foreign country Foreign Inland Transit?
(Example: Berlin to Hamburg)

WAREHOUSE / STOCK / PROCESSING INFORMATION

1. Please provide a breakdown of the goods and/or merchandise to be shipped (detailed description of goods and/or merchandise):

Does the applicant require coverage for the insured goods while in storage (outside the normal course of transit)? If yes, please provide a list of named locations with applicable information and/or attach an updated Statement of Values (SOV) table

FRAUD STATEMENT

(Not applicable in the states mentioned below where a specific warning applies.)

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to a civil penalty or fine.

Alabama

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

Arkansas, District of Columbia, Louisiana, Rhode Island, West Virginia

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kansas

Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Kentucky

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

Maryland

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey, New Mexico

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Ohio

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon

Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Pennsylvania

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Pennsylvania (Auto)

Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000.

Tennessee, Virginia, Washington

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

New York

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

New York (Auto)

Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

Applicant / Named Insured:

Agent/Broker: