Freight Pro Liability Proposal Form

Download the Proposal form in .pdf format

All fields marked with a * are mandatory.

(A) DETAILS OF APPPLICANT (Policy insured name)

Name of the company: *

Date Company Established:

Street Address: *

City / Town*

Postcode: *

State: *

Country: *

Phone Number: *

Paid up share capital: *

Name of contact person: *

Phone Number: *

Fax Number: *

Do subsidiaries / branch offices exist?

Yes

If yes, please mention respective addresses:

(B) DETAILS OF BUSINESS AND PERSONNEL

Total number of staff:*

What trade associations is your company a member of?

Experience of Senior Management: *

Name

Title

Previous organization

Years with organization

(C) FINANCIAL DETAILS

Gross Freight Receipt (for the services to be insured)

(GFR = All business transaction LESS payments to subcontractors LESS customs duty & LESS sales tax. Please add the payment to subcontractors if your company has a subcontract to a third party)

Estimated GFR turnover for proposed period

Select a Currency

* Please provide estimated annual GFR breakdown or % breakdown (total) 100% to be tallied with the total GFR declared above by business activity for the proposed policy period:

Your percentage fields must total to 100%.

Services	%
Seafreight
Airfreight
Warehousing

	%
Packing
Customs Clearance
Trucking

Region: A percentage of all activities (total 100%)

Your percentage fields must total to 100%.

Region	%
Within Malaysia
USA/Canada

	%
Rest of the world
Sanctioned country

OPTIONS

*Coverage may be excluded or limited under the policy with respect to these countries or other countries which may be subject to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the applicable jurisdiction, European Union, United Kingdom or United States of America. i.e Myanmar, Syria, Iran, etc.

Percentage % of GFR for these commodities: (total 100%)

Commodity

Your percentage fields must total to 100%.

Electronic goods
Dangerous goods

Project cargo
Bulk cargo

Valuable cargo
Refrigerated cargo

General cargo

Project cargo definition: any item including packing with weight greater than 7 metric tonnes or with dimensions more than 5m length, 2.5m wide, 2.5m height.

Do you issue any house transport documents?

(a) House Bill of Lading

Yes

(b) House Air Way Bill

Yes

If so, please submit a copy of your transport documentation with the wording clearly visible

Attach file

Information needed on EACH warehouse contracted for storage usage more than 3 months (and also other new warehouse owned/leased/contracted and managed by the Insured that has not been declared before). Please also specify each warehouse is owned/leased/managed/third party warehouse

Please attach separate sheets if there are more than 3 locations.

Attach file

*How many vehicles are owned/leased/managed for carrying goods, and what type of vehicles?

Do you charter vessels or aircraft? (excluded in the policy)

Yes

NOTE:

You are to disclose in this form fully and faithfully all facts you know or ought to know, otherwise the policy issued hereunder may be void.
Liability is not attached until the proposal has been accepted by the insurance company.
Any changes in the information given must be reported to the Company immediately or else the Company will reserve the right to decline all liability.
All fields marked with a * are mandatory.

Date printed