JNGrace Online, The Internet Insurance Agency

Transportation/Cargo Insurance

Quotation Form and Application

General Information

Name:
Company Name:
Email address:
Street:
City:State:Zip:
Phone:Fax:
Nature of Business:

Application Sections

Please complete the appropriate application section(s)

International Cargo
U.S. Domestic Cargo

International Cargo

Shipping Details

Commodity From To % of Annual Sales % by Ship % by Air
(1)
(2)
(3)
(4)

Who Packs Containers?You Professional Packer
Manufacturer Freight Forwarder
Shipping Company

Where are shipments normally unpacked?Port of Discharge Warehouse
Are shipments consolidated in containers
with cargos of other shippers?		yesno
Annual Value of International Shipments:

Limits of Liability

Per Vessel(under deck) Per Barge
Per Vessel(on deck) Per Mail or Parcel Post
Per Aircraft

Optional Coverages

War Risk on Imports/Exports yesno
Duty on US Imports yesno
"Contingency" on Imports/Exports yesno
Other

Valuation Clause

Please select one of the following valuation clauses
"The amount of the invoice (including all charges in the invoice) plus any pre-paid or advanced or guaranteed freight not included in the invoice plus 10% of the sum of foregoing items."
"(same as above plus) or at a higher amount if declared prior to the arrival of the vessel at destination and prior to any known or reported loss or acident."
Other, please describe:

We do not need Domestic Cargo coverage - jump to the end of the form

Domestic Cargo

Shipping Details

Limit of Liability:
Principal Commodities:
Annual Value of Domestic Shipments:

Show approximate % of how values are shipped:
Railroads %Messengers %
Common Carriers %Appicant's Own vehicles %
Contract Carriers %

All policies

Coverage Options

Per Exhibition
Per Warehouse (#1) Location
Per Warehouse (#2) Location
Per Warehouse (#3) Location

General Info - Very Important

Gross Annual Sales:
Present Insurance Company:
Other Info:

Premium/Loss Experience

YearPremiumLosses



Please submit this form for a quote. Our goal is to provide you with a quote within 48 hours.
Thank you for your request.

This form can also serve as the application for insurance. Please print the form out now so that it can be sent to J.N. Grace & Co., Inc. should coverage be desired.

FRAUD STATEMENT - NEW YORK INSURANCE LAW:

Any person who knowingly and with intent to defraud any insurance company or other person files any application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

Signature of Applicant:_______________________________
Print Name and Title:_______________________________
Date:___________________


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