Fidelity & Marine - Products - Applicant Information Sheet

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Terms and Conditions

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Terms and Conditions

Personal

Applicant Information Sheet for Household Goods and Personal Effects

Insured's Name:

Address:

City: State: Zip:

Country:

Phone: Fax:

Email:

Estimated annual values of shipments to be insured in US Dollars:

Current Year:

Last Year:

Premium/Loss history for last three years in US Dollars:

Most Frequent Destinations:

From:

To:

Annual Percentage (%) Breakdown of Shipments:

New Automobiles, Buses and Motorbikes:

Used Automobiles, Buses and Motorbikes:

Household Goods and Personal Effects:

	Average value of any one shipmnent	Percentage of mode of shipment
By Sea
By Air
By Land

Anyone unnamed location within the normal course of transit:

Name of your current insurance broker:

Are you satisfied with their claims handling:

Yes No

Are you satisfied with their rates:

Yes No

Expiration date of current policy:

Any remarks that you would like to share with us?

Mailing Address: P.O. Box 284, 15476 NW 76 Ct - Miami Lakes, FL 33016
Tel: (305) 556-1488 Fax: (305) 556-3680