Insurance Request Form - Emet Insurance

1 Beneficiary

2 Cargo Information

3 Remarks

CERTIFICATE OF INSURANCE REQUEST

PLEASE NOTE: You can fill out this form OR send us a copy of the Commercial Invoice & BL / AWB / BOL, by clicking here!

Please fill out any field you do not have information for with N/A

Today's Date

Beneficiary

Address

City

Zip Code

Country

Email

Is the Consignee different from the Beneficiary?

YesNo

Consignee

Address

City

Zip Code

Country

Description / Comodity

0 /

Declared Valuein USD ($)

Freight (optional)in USD ($)

Mode of Transporation

AirOceanGround InternationalGround Domestic

Coverage

All RiskTotal Loss

Carrier

Vessel / # Voyage

BL # - AWB - CP

Port / Airport of Origin / Departure Country

Port / Airport of Discharge / Destination Country

Remarks

0 /

Prepared Byfirst name & last name

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