EUROPEAN-AMERICAN INC.

MARINE CARGO Insurance Questionnaire
Please complete and return to EurAm
Company Name Street
Type of Applicant City
Telephone: County
Telefax: State / Zip
Website: e-mail
  Federal Employer ID Number
Nature of Business - Manufacturer, Exporter, Broker, etc.
Description of Goods
Packing (Describe in detail, provide pictures or illustrated catalogs)
Geographical Scope
Other (Specify)
Principal Trading Areas (Name Countries)
From
Via (Port)
To
Estimated Annual Volume (Indicate % Insured)
Valuation Basis
 

Amount of invoice, including charges, plus ocean freight, plus %

 Other specify

 

LIMITS OF INSURANCE REQUIRED

Vessel
$

Aircraft
$

Inland Transit
$

Parcel Post (per Package)
$

Warehouse Limit - Location #1
$

Address:

Warehouse Limit - Location #2
$

Address:

Warehouse Limit - Location #3
$

Address:
Other specify


INSURING CONDITIONS REQUIRED
"All Risks" Other Terms (Specify) Deductible $
War/Strike Duty Warehouse End.

FOB/Free on Board

FAS/Free Alongside Ship

Inland Transit Other specify

 

PREMIUM/LOSS RECORD (3 YEARS)
Year
Premiums paid
Losses paid
Outstanding
Principal Cause(s) of Loss(es)
$
$
$
$
$
$
$
$
$
Totals
$
$
$

 

PRESENT INSURANCE COVERAGE
Insurance Company Insuring Conditions/Deductible
Additional Comments  

Note: Completion of this application does not constitute a binder or obligate the applicant to purchase this insurance.

 

Desired Effective Date:    
Name: Title: Date: