Annual Policy

*First Name:

*Last Name:

*Street Address:

Street Address 2:

*City:

*State/Province:

*Country:

*Zip Code:

*Limit (For each vessel/aircraft or truck):
Please state the highest limit in terms of insured value on one vessel or aircraft (if it's an air shipment) or on one truck if it's domestic shipment by truck

*Limit (For each location):
Please state the average insured value per store or per warehouse at one time

*Full Description of Goods Shipped:

*Shipped From:

*Shipped To:

*5 Year Claim Record:

*Est. Annual Turnover:

*Do you require storage coverage?:

Yes

If yes, please fill out the following:

Name and address of warehouses where goods will be stored:

*Limit required at each warehouse:

*Average in store at any one time (For all warehouses):

*Details of security and protections of each warehouse:

*Do you require coverage for inland transit?:

Yes

*Estimated annual value of inland transits:

*Limit per vehicle:

*How did you find us?:

*Company Name:

*Contact Name:

*Phone:

*Email:

*Fields Are Required