16th May, 2008 | 14:31:34 BST

Proposal Forms

Cargo Liability Insurance Form

ITIC Ltd, International House, 26 Creechurch
Lane, London EC3A 5BA.
Tel. +44 (0)20 7338 0150 Fax +44 (0)20 7338 0151
E-mail ITIC@thomasmiller.com
Website www.ITIC-insure.com

[Download this form in Word 6/95 format]

1. General Information

Company Name:

Main Activity:

Address:

Telephone:

Fax:

E-mail:

2. Insured activity for which insurance required:

Please tick the services you provide and estimate your gross freight receipts (excluding customs duties or taxes paid on behalf of customers) from each. Please also indicate currency e.g. US $:

Freight forwarder

NVOC (issuing Bs/l)

Haulier

Warehouse keeper

Packer/consolidator

2.1 What percentage of your annual gross freight receipts results from carriage of cargo which is:

Breakbulk (%)

Approximate tonnage

Containerised (%)

Approximate number of TEU’s

Palletised (%)

Approximate tonnage

2.2 What percentage of your traffic is to or within each of the following:

UK (%)

Europe (%)

North America (%)

Middle East (%)

Africa (%)

Australasia (%)

Central & S. America (%)

Indian sub-Continent (%)

Far East (%)

2.3 What percentage of your annual gross freight receipts is represented by:

Refrigerated cargoes (%)

Tobacco products (%)

Tank containers (%)

Project cargoes (%)

Spirits (%)

Dangerous cargoes (%)

High value goods (%) (audio-visual equipment, jewellery, cameras etc).

2.4 Do you operate your own warehouse(s) or packing/consolidation facility(ies)?:

Please detail location(s):

Do you have a Customs bond? yes no

Do you issue T1 forms? yes no

3. Trading conditions and documentation:

Please tick the conditions of business and documents you currently use:-
Conditions of business:

National ship agency association conditions

Own house b/l ‡

National forwarding association conditions

TT Club b/l

National haulage association conditions

CMR/CIM consignment note

Own conditions ‡

House airwaybill ‡

FIATA b/l

Forwarder’s certificate of receipt

Other (please specify) ‡

‡ Please attach a copy:

Own conditions: †

Own house b/l: †

House airwaybill: †

Other: †

4. NVOC bills of lading

Do you issue your own nvoc/house bill of lading? yes no

Is your nvoc/house bill of lading issued by any other party (eg. your agents in other countries)? If this is the case, you will need to provide full details of volumes, names of agents, etc. yes no

5. Limits and Deductibles:

Please indicate any preferred limits or deductibles:

Alternative 1

Limit

Deductible

Please state currency

Alternative 2

Limit

Deductible

Please state currency

We declare that the information and answers given in this form are true to the best of our knowledge and belief and that we have not misstated or suppressed any material facts that might influence the Club’s assessment of the risk. We also understand that completion of this form does not bind either the Club or ourselves to accept this insurance but, if terms are agreed, it will form part of our contract with the Club.

This proposal form must be completed by a person who is authorised to bind the proposer.

Name:

Position in company:

Date:

† The total aggregate size of all your attached files should not exceed 1Mb.

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