Marine Cargo Insurance Form

IMPORTANT: This proposal forms the basis of the Insurance contract between the Insured and the Insurer once completed by the Insured and accepted by the Insurer. Making a false statement or withholding any material fact may give the Insurer the right to repudiate any claim made under the policy or may result in the policy being declared null and void from inception. A material fact is any fact, which influences the acceptance of the risk or conditions, and premiums on which it is accepted. This proposal must therefore be fully/accurately completed and signed by the proposer.

Name of Proposer:

Postal Address:

Physical Address:

Telephone Number:

Contact Person:

Fax:

Email:

Date business was established:

Vat Number:

Have you traded under a different name: Yes/No (if Yes, specify):

Description of goods carried requiring insurance cover:

Maximum load limit required in respect of Cargo

What pre-employment investigations are carried out on Drivers and Crew:

What anti-hijack/theft precautions do you enforce:

How many drivers/crew per vehicle

Are your vehicles fitted with any of the following?

Number of Vehicles fitted with tachograph:

Number of Vehicles fitted with alarm system:

Number of Vehicles fitted with immobiliser:

Number of Vehicles fitted with two way radio / cellphone:

Number of Vehicles fitted with tracking device (specify type):

Please provide Territorial Limits Required:

Are your loads currently insured? Name of Insurer:

Have you previously had this cover? Name of Insurer:

Provide details on the security used:

Cargo Claims (3 Years) Date of Loss:

Gross Amount of Loss:

Cause and Commodity:

Cover Required 11.1 All Risks:

DECLARATION OF THE PROPOSER:

I hereby declare that the above particulars and answers are true and complete in every respect, and that no material fact has been suppressed or withheld, and I undertake to exercise all ordinary and reasonable precautions for the safety of the property, and I further declare that if such statements and particulars are in the writing of any person other than myself, such person shall be deemed to have been my agent for the purpose, and I agree that this declaration and the answers given above shall be the basis of the contract between me and the Company, and I further agree to accept a Policy subject to the usual conditions prescribed by the Company and endorsed on their Policy, and to pay the premium thereunder when called upon to do so.

Signing this form does not bind the Proposer to effect this insurance, but is it agreed that this form shall be that basis of the contract should a policy be issued.

Name:

Position Held at Company:

Proposer's Signature:

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Marine Cargo Insurance Form

Are your vehicles fitted with any of the following?