Untitled Document

Applicant
Surname or company name
Given name(s)
Postal address
Private telephone number
Business telephone number
Facsimile
Business or occupation
Years in business
Email address

Goods to be insured

Details of goods imported to be insured

Details of goods exported to be insured

Details of movement of goods inland to be insured

Details of transits and other options required

Please tick options required and provide details

Imports from
Exports to
Inland from
Other - specify

Conveyances:
Road - professional Rail Sea Air
Post Own vehicles

Usual packaging

1. Overseas
Fully enclosed containers (FCL/LCL)
Open/flat rack containers or similar
Other Provide details of packaging

2. Inland transits: Provide details of packaging

For imports or exports cover please specify whether you require

Exhibitions/demonstrations Number per year Limit required
Sellers contingency Annual FOB/C&F export sendings Limit required
Strikes diversion Limit required
Insufficiency of packaging
Sealed container clause

For inland cover please specify whether you require

Cover A (Accidental Damage)

Cover B (Specified Events)
Specify whether you require optional cover for:
Theft/non-delivery Dropping during loading/unloading

Please also specify if any of the following Australia-wide cover options are required

Exhibitions/demonstrations Number per year   Limit required
Travellers samples Number of vehicles   Limit required
Tools of trade (Restricted cover) Number of vehicles   Limit required

Basis of valuation required

Imports/Exports

Cost Insurance and Freight plus + duty or
Other - Please Specify

Inland

As per Insurers' Local Goods in Transit Cover or
Other - Please specify

Previous History

Policy Year	Imports		Exports		Inland
Policy Year	Sendings or Turnover	Claims	Sendings or Turnover	Claims	Sendings or Turnover	Claims
Current Year
Previous Year
Previous Year
Previous Year
Previous Year

Please tick Yes or No and give details as requested	Yes	No
1. Has any insurer at any time declined your proposal for insurance? If Yes, please provide details:
2. Has any insurer at any time cancelled or refused to renew your policy? If Yes, please provide details:
3. Has any insurer at any time imposed special conditions/rates as a result of your policy history? If Yes, please provide details:
4. Are there any other relevant facts relating to the risk to be insured which you should disclose to enable a true assessment of your Application before acceptance? If Yes, please state the facts: