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Freight Forwarders & Customs Broker Application for Legal Liability and Errors & Omissions Insurance

IMPORTANT NOTE:

The questions contained in this form are designed to give Insurers information regarding your business.  It cannot always cover every aspect and it is your duty to disclose all material information to Insurers that may affect the premium or conditions. This form should be completed by you or with your Insurance Broker who will be able to assist you in a professional capacity regarding these points.

Company Information
*Company Name:  
*Address:  
*City:   *State:  
*Zip Code:   *Contact Name:  
*Phone: ()   Fax: ()
*E-Mail:   
Website:
*Years in Business:   *Corporation Type:  
No. of Employees: No. of Branches:(USA):        Overseas:
Company Type:






Other:
(Please Specify)
*As a Customs Broker, what is the approximate number of entries handled in for a 12-month period?  
*Current OTI Provider:  
*Existing Policies:
(check all that apply)




Other:
(Please Specify)

Quality Control
*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?
*Does your Company currently hold or, in 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: (must add up to 100%)
*International Ocean %  *USA/Canada % *India/Pakistan %
*International Air %  *Mexico % *China %
*Domestic Air %  *Cntrl/Sth America % *Far East %
*Domestic Truck %  *Middle East % *Africa %
*Domestic Rail
% 
*Europe % *South Africa %
*Soviet Union % *Australia
%
What percentage of shipments are containerized? %
What percentage of shipments are break bulk? %
What percentage of traffic do you carry as the principal? %
What percentage of traffic do you carry as the 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 TEU’s Tonnage GFR
Ocean $
River $
Road $
Rail $
Air $
TOTAL: $
PLEASE NOTE GROSS FREIGHT 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 GFRs above:
Warehousing: Customs 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
BMC 34 Number: .  SCAC Code:
*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 & Consolidation
*Do you operate your own warehouse, with your own personnel?
*Do you perform consolidations/de-consolidations within your warehouse?
*Do you handle long-term storage?
*Do you act as a distribution location for 3rd parties?
*Do you have refrigerated storage?
*Do you provide open (outside) storage facilities?
*What is the square footage of your largest warehouse? Sqft 

Cargo
What percentage of your traffic does the following represent?
*Personal Effects %  *Temperature Controlled Goods % 
*Liquor/Tobacco %  *Various General Cargo % 
*Bulk shipments %  *Electronic Equipment % 
*Project Cargo %  *Tank Cargo % 
*Do you currently have or require cargo insurance?
*Would you like our office to provide a qoute?

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? (Forward legible hard copies)
*Own House Bill of Landing  
*House Airway Bill (International)  
*Domestic House Bill  
*Warehouse Receipt  
Please indicate your limit of liability for the following:
*Domestic Transit Limit:   (If other, please specify)
*Storage Limit:   (If other, please specify)
*International Air Limit:   (If other, please specify)
*Ocean Limit:   (If other, please specify)
*Do you require evidence of insurance from subcontractors?
*Coverage is not automatically included for declared values, do you accept cargo for shipment on a “Value  Declared” basis?
Principal carrier(s) used:
*Current Insurance Company/Insurer:  
*Policy No.:  
When does existing insurance policy expire?
Current policy limit of liability: CLL E & O:
Current policy deductible for: CLL E & O:
Has insurance ever been cancelled or declined?

Past Loss History Paid & Outstanding: (past 3 years)
Year Paid Premium Claims (Paid - Expenses - Reserves)
Current
Current Less 1
Current Less 2
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. Insurers strongly recommend 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:   *Title:   *Date signed: