Global Insurance Network Coverholder at LLOYD's
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Cargo Insurance Application

Cargo Insurance Application
Company Information
Company Name:  
State: Zip
Contact Name:  
Years In Business: Public Corporation Private Corporation
No. Of Employees  
No. Of Branches:  
Company Type:    
Freight Forwarder Trucking Tank Container Operations
Warehouse Operator Air Cargo Agent Customs Broker
N.V.O.C.C. Stack Train Operator Road Hauler
Ship's Agent      
Please Specify
As a Customs Broker, what is the approximate number of entries you handle for a 12-month period?
Existing Policies: (check all that apply)
Cargo Hull Errors & Omissions Motor Truck Cargo
Cargo Legal P & I Property & Casualty Bailee
Please Specify
Five Most Frequently Handled Commodities:
Principal Trading Areas by Percentage
Domestic USA % Canada % Mexico %
Far East % Western Europe % Central America %
South America % Austraila/New Zeland % Africa (excluding S. Africa) %
South Africa % Former Soviet Block % Eastern Europe %
Middle East % Other %    
Maximum insured value per conveyance: $
Maximum insured value per container: $
Maximum insured value per storage location: $
If cargo all risk for storage is required, please attach a list of locations including construction and protection
Describe Packing Methods Used
Ex: Containerized, Breakbulk, Ro-Ro, Crated, Professional, Owner-packed
Number of Domestic Shipments Per Month:
Number of ocean export shipments per month:
Number of air export shipments per month:
Number of ocean import shipments per month:
Number of air import shipments per month:
Estimate values shipped & handled annually: $
Average value per shipment: $
Percentage of shipments currently insured: %
Annual premium volume: (avg. past 3 yrs): $
Warehousing & Distribution


Please provide two (2) originals of your warehouse receipt and a copy of the alarm certificate. Along with the central station alarm system, the insurance company requires you have video surveillance with digital backup and motion sensors on walls and ceiling. They also require cellular backup in case the phone lines are cut in case of a break-in.

Do you own or lease the following location(s)?
Location Address (if different):
Building Construction: Age of Building:
Roof Construction: Wall Construction:
Sprinkler Systems? Central Alarm System?
Warehouse Square Footage: Is the Warehouse Dock Height?
Number of Bay Doors (if any): Do you issue a warehouse receipt?:
Warehouse Payroll: $

Distribution & Consolidation
Do you operate your own warehouse, with your own personnel?
Do you perform consolidations within your warehouse?
Do you perform de-consolidations within your warehouse?
Do you handle long-term storage?
Do you hold stocks for 3rd parties or act as a distribution location?
Do you have refrigerated storage?
Do you provide open (outside) storage facilities?

What percentage of the following do you maintain in your warehouse(s)?
Canned Foods % Computers & Supplies % Alcohol Wines & Spirits %
Cloth Products % Furniture % Tobacco %
Paper Products % Electronics % Palm Pilots/IPODS %
Tires % Plasma/LCD Televisions % Industrial Chemicals %
Auto Parts % Foodstuff %   

Past Loss History Paid & Outstanding: (past 3 years)
Year Premium Paid Losses Loss Ratio Reserves Recoveries
Last Year
Previous Year
Next Previous Year
How many claim files are opened annually?:
Does your current insurance company pursue recoveries?:
If yes, enter the annual recoveries:
Current Insurance Broker:
Policy Number:
Current Insurance Company:
How long has your current policy been in effect?
Additional Information:

To the best of knowledge the information contained within this application is accurate

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Global Insurance Network, 8350 NW 52nd Terrace, Suite 418, Doral, FL 33166
Phone: (305) 599-0900     Fax: (305) 599-1114

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