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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:
YEAR GROSS PREMIUM PAID LOSSES OUTSTANDING LOSSES

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