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Applicant Information Sheet for General Cargo

Insured's Name:
City:        State:        Zip:
Phone:        Fax:  

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:

Annual Percentage (%) Breakdown of Shipments:
    Approved General Merchandise and/or General Cargo:
    Electronic Precision Instruments, Consumer
    Electronics and Machinery which is prone to Breakage
    (Encluding Mobile, Cellular Telephones):
    Computers and Computer Related Equipment:
    Fragile Goods:
    Bottled Products, Excluding Beverages:
    Food Items and Pharmaceutical Products in Tins,
    Cans, Paper, Sachets, Liquid Items in Tins:
    Bottled Beverages (Liquors included):
    New Automobiles, Buses and Motorbikes:
    Used Automobiles, Buses and Motorbikes:
    Household Goods and Personal Effects:
    Frozen Food other than Frozen Meat:
    Frozen Meat:
    Steel Sheets, Coils, Bars, Billets and the like:

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