wayne parryFreight Insurance

Cargo Insurance Application Form

Name of Insured:
Address:
Vessel or Conveyance:
Voyage No / Flight No: Date of Departure:
From (City / Port): (Country)
To (City / Port): (Country)
Via (City / Port): (Country)

  On Cargo As Described Below:
 

  Marks and Numbers:
 
  Sum Insured as follows:
I herely declare that to the best of my knowledge and believe the above particulars are true and correct. Invoice Value $
Freight & Sundry Charges $
Duty Applicable $
% Mark up $
  Value for Insurance $
Name:
Company Name:
Contact Phone Number: