Liability/E&O Form - ENG - Emet Insurance

APPLICATION FOR LOGISTICS & TRANSPORTATION PROGRAM

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GENERAL INFORMATION

Company NameCompany that is insured

Company Physical AddressEntire Address (Including city, state, and zipcode)

No. of Employees

Years in business

Full NamePoint of Contact's Full Name

PhonePoint of Contact's Phone Number

E-mailPoint of Contact's E-mail

Policy Effective Date

Please indicate any association or organization you are member of

0 /

SERVICES & OPERATIONS

Please indicate what services you provide

0 /

Do you offer Marine Cargo Insurance to your customers?

YesNo

Please indicate the percentage for each type of cargo (approximately).
Input "0" for the categories that do not apply to your company.

General Cargo

Electronics or Electronic Equipment

Perishables / Temperature Controlled

Machinery and Heavy Equipment

Oversize Load

Chemicals and Hazardous Materials

GEOGRAPHICAL SCOPE

Please indicate the percentage for the geographical scope your company has (approximately).
Input "0" for the categories that do not apply to your company.

USA & Canada

Latin America

Europe

China/Japan

East Asia

India/Pakistan

Middle East

Africa

SALES

Sales for previous 12 months

Sales for the next 12 months (Approx.)

Percentage of sales for the next 12 months (Aprox.) by Services

Percentage of sales for Freight Forwarder/Transportation Broker

Percentage of sales for Indirect Air Carriage

Percentage of sales for Customs Broker

Percentage of sales for Motor Truck Cargo

Percentage of sales for NVOCC

Percentage of sales Warehousing

CLAIM HISTORY

Year

Claim Amount

Total Cost

Description

Year

Claim Amount

Total Cost

Description

Year

Claim Amount

Total Cost

Description

UPLOAD DOCUMENTS

Uploading additional documentation is not mandatory but will help us provide you with a more precise quote!

Type of DocumentPlease select all that apply

Bill of Lading (BL)Air Way Bill (AWB)Warehouse ReceiptBill of Sale (Ground)

Fileupload

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