MARINE CARGO PROPOSAL FORM

Name & Address of the proposer*
Phone No
Fax No
Name & Address of the broker
Phone No
Fax No
Cargo Details
Description
Nature of packing
Other, please give details
Other, please give details
Voyage/Transit Details
From:
To:
Mode of transport
Sea: (%)
Air(%)
Rail/Road (%)
Sums Insured
Limit per Boltorm
Basis of Valuation
What are the Imports/Exports Terms of Sales
Has the proposer ever made a Marine Cargo Insurance Claim and if so provide details
Date Of Loss Details Claim Values (NZ$)
Type of Policy Required
Risk to be covered:
Expected date of start of voyage :
Has the Proposer’s Insurance ever been declined, cancelled or refused by another insurer and if so provide details
Insurer Policy No Details
Any other information:
We understand that the above information, which is correct to the best of my knowledge, is to be the basis of insurance, if a policy is issued, but does not obligate me to accept the insurance nor oblige the insurer to effect insurance on the risk
Name of the applicant :
Date :