1. Name of the Insured: 2. Address of the Insured: 3. Description of operations: 4. Details of where the Insured s responsibility for incoming and out
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1 STOCK THROUGHPUT INSURANCE APPLICATION Agency Name: Agency Contact: Agency Agency Phone: Agency Address: Agency City: Agency State: Agency Zip Code: Currently an agent for Agent Access?: YES NO Agency Comments: StockThroughputInsurance.com :: Agents Access :: :: Page 1 of 8
2 1. Name of the Insured: 2. Address of the Insured: 3. Description of operations: 4. Details of where the Insured s responsibility for incoming and outgoing transits begins and ends: 5. Estimated total sales for forthcoming annual period (USD): Actual total sales for last annual period (USD): 6. Required deductibles: a) Transits (USD): b) Stock/Inventory (USD): 7. Attachment/renewal date for the policy: 8. How are the goods valued/what is the basis of loss settlement required in respect of: a) In raw state (prior to manufacture) b) Storage prior to manufacture c) During manufacture d) Storage after manufacture e) Distribution to final customer Is merchandise to be put on exhibition? YES NO If yes: a) Number of exhibitions per years b) Estimated value at any one time and place c) Locations involved IMPORTS: 9. What is the nature of the goods? StockThroughputInsurance.com :: Agents Access :: :: Page 2 of 8
3 10. What is the estimated annual total values shipped including inter-company transits: USD Split as follows: Imports into the country of the Assured s operation form: Country/ Continent Total Annual Value Shipped Percentage purchased C.I.F or similar basis Percentage purchased F.O.B. AND C. and F. or similar basis 11. What are the methods of transit (as a percentage of total imports): Means Percentage of Any one conveyance total imports Average value (USD) Max Value (USD) a) Airfreight % b) Seafreight % c) Road % d) Rail % 12. Packing Full container loads % Part container loads % Break Bulk % Details of product packing: StockThroughputInsurance.com :: Agents Access :: :: Page 3 of 8
4 EXPORTS: 13. What is the nature of the goods? 14. What is the estimated annual total values shipped including inter-company transits: USD Split as follows: Exports into the country of the Assured s operation form: Country/ Continent Total Annual Value Shipped Percentage purchased C.I.F or similar basis Percentage purchased F.O.B. AND C. and F. or similar basis 15. What are the methods of transit (as a percentage of total imports): Means Percentage of Any one conveyance total imports Average value (USD) Max Value (USD) a) Airfreight % b) Seafreight % c) Road % d) Rail % 16. Packing Full container loads % Part container loads % Break Bulk % Details of product packing: StockThroughputInsurance.com :: Agents Access :: :: Page 4 of 8
5 DOMESTIC TRANSITS: 17. What is the nature of the goods? 18. What are the estimated total annual values (not where overseas movements are involved) including inter-company transits? USD 19. What are the modes of transits (as a percentage of the total domestic transits): a) Carried by road/rail carriers % b) Carried by own vehicles % 20. Please give details on any waivers of recourse given to third party road/rail carriers? Do road/rail carriers take full value liability? YES NO 21. Means Percentage of Any one conveyance total imports Average value (USD) Max Value (USD) a) Airfreight % b) Seafreight % c) Road % d) Rail % STORAGE OF INVENTORY (other than in the ordinary course of transit) 22. Provide name and address (including ZIP code) of all warehouses used (please attach schedule if available): Name Address State Zip Average monthly values stored (USD) Max monthly values stored (USD) StockThroughputInsurance.com :: Agents Access :: :: Page 5 of 8
6 23. Please complete this Statement of Values worksheet and it to us. In so doing, please supply details of each of the main locations (exceeding USD 2 million in store) such as details of construction, sprinkler and alarm systems, HPR (highly protected risks) rating and/or copies of survey information. Please provide COPE (Construction, Occupancy, Protection, Exposure [property insurance]) information if available. 24. What is the turn-around time of goods in storage? 25. Is there any retail exposure? YES NO If yes: Name Address State Zip Average monthly values stored (USD) Max monthly values stored (USD) CLAIMS: 26. Please provide claims experience for (at least) the past three years as below on a gross basis but indicating the applicable deductible, if any: a) Marine/Transits Claims Record: Year Cause of loss Claims Paid Claims Outstanding Deductible b) Storage Claims Record: Year Cause of loss Claims Paid Claims Outstanding Deductible StockThroughputInsurance.com :: Agents Access :: :: Page 6 of 8
7 27. Please give more detailed information on any major claims and details of action taken to prevent reoccurrence of such claims: 28. Please give details of any uninsured losses not included in the above: ADDITIONAL INFORMATION: Please give details of any other information that would be material to Underwriters (material means information which is likely to influence the acceptance of the risk and the terms applied): StockThroughputInsurance.com :: Agents Access :: :: Page 7 of 8
8 Declaration I declare, that to the best of my knowledge and belief, the statements and particulars in the proposal are true and that no material facts have been mis-stated or suppressed. I agree that this proposal, together with any other information supplied, shall form the basis of any Contract of Insurance affected thereon. I undertake to inform Insurers of any material alteration to facts occurring before completion of the Contract of Insurance. Please state the name and title of the officer at your firm who has prepared and reviewed this questionnaire and sign the declaration. Name: Date: Position: Signature: StockThroughputInsurance.com :: Agents Access :: :: Page 8 of 8
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