Freight Forwarders Liability - Mar Risk

1 Freight Forwarder1 GENERAL INFORMATIONName of InsuredMain AddressTelephoneFAXE-mailWebsiteOther addresses/locationsYear establishedNumber of Employees:Full TimePart TimeDirectors/Officers/Partners2 INFORMATION ABOUT YOUR OPERATIONSWhat are your total Gross Freight Receipts for:Next Year (estimate)USDC urrent YearUSDLast YearUSDTwo Years AgoUSDP lease complete the following table to indicate classes of goods handledAs AgentAs Principal%Volume% GFRC ontainerisedY / NY / NContainerised(temp controlled)Y / NY / NGeneral CargoY / NY / NBulk CargoY / NY / NLivestockY / NY / NDangerous CargoY / NY / NChemicals/OilsY / NY / NTobacco(inc cigars/cigarrettes)Y / NY / NPersonal EffectsY / NY / NAlcholic spiritsY / NY / NCD/PC/Computer Games/DVD/Laptops, etcY / NY / NMobile, cell phones, etcY / NY / NJewellery, works of art, precious goodsY / NY / NOther hight value goods-please specifyY / NY / NMarRSDo you anticipate involving yourself in any project cargo movements?

2 If so please supply GEOGRAPHICAL AREAS OF OPERATIONP lease indicate the areas of the world you trade in as follows:% Road % Rail% Sea% AirAfricaAustralasiaChinaCISC entral/South AmericaEuropeFar EastIndia and subcontinent ItalyMexicoMiddle EastUSA/Canada4 YOUR TRADING CONDITIONSP lease advise which of the following you issue and provide a copy of same:Bill of LadingY / NMultimodal Transport DocumentY / NSeawaybillY / NAir WaybillY / NConsignment NoteY / NFreight Forwarders billY / N5 INFORMATION ON YOUR INSURANCE HISTORYFor the last three years please indicate your broker and insurance company:Current BrokerBroker, last yearBroker, 2 years previousInsurer, currentInsurer, last yearInsurer, 2 years previousHas Any Insurer :i). Ever cancelled your insurance?Y / Nii). Refused to renew any aspect of your insurances?Y / Niii). Declined to insure any aspect of your insurances?

3 Y / NIf you have answered YES to any of the above please provide us with some details:6 YOUR CLAIMS HISTORYP lease provide your claims record for the last 5 years. Figures entered should be fromthe ground up , without application of your excess/deductible at the USDO utstanding USD Total USDC urrentLess oneLess twoLess threeLess fourPlease detail any claim over USD 25,000 as of ClaimPaid USDO/S USDFees USDT otal USD7 YOUR INSURANCE REQUIREMENTSP lease indicate the limit you require:LimitUSDP lease indicate the excess/deductible you requireUSD8 ANY OTHER INFORMATIONP lease detail any further information that may be material to the risk. Please feel free to attachany additional sheets and DECLARATIONWe declare that the information and answers given in this form are true to the best of our knowledge and belief and that we have not mis-stated or suppressed any material facts that might influence Navigator's assessment of the risk.

4 We also understand that completion of this form does not bind either Navigators or ourselves to accept this insurance but, if terms are agreed, it will form part of our contract with :Position:Date.