Global Insurance Network, Inc.

A World of Service for Worldwide Services!

Todays Date:
Insured Value:

From:
Via:
Destination:

Name of Airline:		AWB#:
Name of Vessel:		B/L#
Name of Common Carrier:		PRO#:
Booking #

Shipper Name:
Shipper Address:
Consignee Name:
Consignee Address:

Complete description of merchandise: (including pieces, packing, crated, boxed, etc.) If containerized please include CONTAINER & SEAL NUMBERS

Loss Payable To:		Date Shipment Leaves
Name of your company requesting the certificate
Contact at your Company:

Phone:		Fax:
Your Reference:		Email:

I certify that all statements and information given on this form are true and correct to the best of my/our knowledge. Any material misrepresentation and/or false information given will result in the voiding and nullification of the certificate of insurance and its respective coverages.

Name:

Title:

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