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Single Shipment Certificate Request

Todays Date:

SHIPMENT INFORMATION
Date of shipment: Shipment from:
Via: Shipment to:
Type of Shipment: Air or Ocean
Name of Airline: Or Name of Vessel:
Name of Common Carrier (Domestic Shipments):
Your Ref. No.:
If Ocean what type of B/L? On-Deck or Underdeck    Voyage No.
B/L or AWB No. or Booking No.: PRO#:
I certify that all statements and information given on this form is 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.
SHIPPER
Name:
Address:
CONSIGNEE
Name:
Address:
Loss Payable To:
VALUATION
INSURED VALUE:
COMMODITY AND PACKAGING
Complete description of merchandise including pieces, packing, crated, boxed, etc. If containerized please include Container and Seal Numbers.
Complete Description:
Container & Seal Numbers:
Number of shipping packages:
How is it packed?
COMPANY INFORMATION
Name of your company requesting the Certificate
Contact at your Company:
Phone:
Fax:
Email:

Skype status
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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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