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Freight Forwarders and Custom Broker Application For Legal Liability And Errors and Omissions Insurance

FREIGHT FORWARDERS & CUSTOM BROKER APPLICATION
FOR LEGAL LIABILITY and ERRORS & OMISSIONS INSURANCE
Company Information
Company Name:  
Address:  
City:
State: Zip
Contact Name:  
Phone:
Fax:
 
E-Mail:  
Website:  
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. Ship's Agent    
Other:
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
Other:
Please Specify
Loss Prevention
Do you employ designated safety officer(s)?
If yes, who?
Do you have a loss prevention program in effect?
If yes, what training and education do you require for employees?
Quality Control
Does your company currently hold, or is it n the process of, certification by a
recognized quality management organization, e.g. ISO 2000/9000?
If yes, please specify
Operations
On a percentage basis, advise the methods of transport used and most common areas shipped to/from:
International Ocean % USA/Canada % India/Pakistan %
International Air % Mexico % China %
Domestic Air % Central/South America % Far East %
Domestic Truck % Middle East % Africa %
Domestic Rail % Europe % South Africa %
    Caribbean. % Australia %
What percentage of shipments is containerized? %
What percentage of shipments are break bulk? %
What percentage of traffic do you carry as principal? %
What percentage of traffic do you carry as agent? %
What percentage of traffic do you co-load with others? %
Volume
Provide Twenty Equivalent Units (TEU’s) or Tonnage and Gross Freight Receipts (GFR) for each of the following modes of traffic:
Mode of Traffic TEUs Tonnage GFR
Ocean
River
Road
Rail
Air
TOTAL
PLEASE NOTE GROSS RECEIPTS ARE TOTAL BILLINGS LESS DUTIES AND TAXES
Please list annual fees or revenues generated from the following operations if not included in your total GFR's above:
Warehousing: $ Custom Brokering: $
Modes of Traffic
Do you own and operate trucks used to move cargo?
If yes, what percentage of Domestic Road traffic is carried as follows?
Up to 100 Miles % Up to 250 Miles % Excess 250 Miles %
Do you act as a carrier, either by contract or some other agreement, with trucking nationwide?
Do you need insurance filings, i.e. BMC 34 (cargo liability) made on your behalf?
Do you perform rail stack operations?
Do you operate combined air/sea services?
Do you consolidate ULD's?
Do you charter aircraft?
If yes, what type of charter(s)?
Do you charter vessels?
If yes, what type of charter(s)?
Do you consolidate containers?
What percentage of traffic is shipped under your bill of lading?
Door-to-door %
Port-to-port %
Do your subcontractors limit their liability to a differing level than that of your own?
Warehousing & Distribution
COMPLETE ONE SECTION FOR EACH WAREHOUSE (MAKE ADDITIONAL COPIES IF NECESSARY)

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?
 
 
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?
Cargo
What percentage of your traffic does the following represent?
Personal Effects % Computers/Laptops % Artwork/Fine Arts %
Liquor/Tobacco % Cell Phones % Antiques %
Haz-Mat/Dangerous %   Electronic Equipment % Temperature Controlled Goods %
Bulk Shipments % Tank Cargo % Precious Jewelry/Stones %
Used Goods % Project Cargo % Various General Cargo %
Do you have an Open Cargo policy to insure your customers' shipments??
Maximum Values
Estimate the maximum value at risk for the following:
Any one shipment of general cargo via ocean or air transportation: $
Any one shipment of general cargo via vehicle or road transportation: $
Any one shipment of personal effects or household goods: $
Any one shipment of liquor or tobacco: $
Any one shipment of temperature controlled goods: $
Conditions of Business
Which of the following apply to your business? (Check all that apply and forward hard copies)
Own House Bill of Lading House Airway Bill
Domestic House Bill Warehouse Receipt
Please indicate your limit of liability for the following:
Domestic Transit Limit $ Storage Limit $
International Air Limit $ Ocean Limit $
Do you require evidence of insurance from subcontractors?
Do you accept cargo for shipment on a "Value Declared" basis?
Principle Carrier(s) used:
Current Insurance Company/Insurer:
Policy No.
When does your current policy expire?
Current policy limit of liability: CLL $ E&O $
Current policy deductible for: CLL $ E&O $
Has insurance ever been cancelled or denied?
Are you aware of any pending claims or potential claims?
(If yes, please provide details on a seperate sheet)  
Loss History Paid & Outstanding: (past 3 years)
Year Paid Premium Paid Claims & Expenses Loss Radio Reserves
Last Year
Previous Year
Next Previous Year
TOTALS
Completion of this application is not a guarantee of coverage. Coverage may be offered upon review and approval of the underwriter. If a quotation is put forward it will contain various terms, conditions and exclusions. The Insurance Company strongly recommends you examine the quotation in conjunction with your Insurance Broker before acceptance.

I hereby confirm that the information given above and in any attached sheet(s) is true and correct.

Name of Applicant :

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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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