FREIGHT FORWARDER LIABILITY INSURANCE RENEWAL FORM

Renewal period

Please tick:

Renew based on the last declaration

Renew and follow the below declaration

1. Estimate GFR for renewal period (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)

*Reason of changes of GFR (if any) and no. staff and vehicle This part only be applicable when GFR amount different from last year declaration

2. Subsidiary/affiliate companies to be named in the same policy, if any

3. Freight forwarding activities to be insured (total 100% with GFR declared) :

Your percentage fields must total to 100%.

Services	%
Seafreight
Airfreight
Warehousing

	%
Packing
Customs Clearance
Trucking

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

Your percentage fields must total to 100%.

Commodity	%
Electronic goods
Dangerous goods


Project cargo
Bulk cargo


Valuable cargo
Refrigerated cargo


General cargo

5. Do you issue any house transport documents?

(a) House Bill of Lading

Yes

(b) House Air Way Bill

Yes

6. Please update :

(a) Date company established - dd/mm/yyyy

Name of the company: *

Date Company Established:

Street Address: *

City / Town*

Postcode: *

State: *

Country: *

Phone Number: *

(b) Total number of employees

(d) Warehouse address if there is any change/relocation

Information needed on EACH warehouse contracted for storage usage more than 3 months (and also other new warehouse owned/leased/managed that not declared before).

Please also specify each warehouse is owned/leased/managed/third party warehouse. Example as per below

Note : If you will use warehouse storage for more than 3 months, please declare the contents.

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

Yes

8. Any optional cover required?

Uncollected Cargo

Yes

Tenant Liability

Yes

Fidelity Guarante

Yes

Airfreight Replacement

Yes

9. Are you aware of any potential claim?

Yes

If yes, please declare.

*Signature

*Company Stamp

*Email Address

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

* Please attach appendix for new risks and/or changes for past declaration not stated in this form

Attach file

Date printed