INDEX OF PROPOSAL FORMS Please select the appropriate form (Ctrl + Click to follow link) A. ARE YOU AN INDIVIDUAL? B. ARE YOU A COMMERCIAL ENTITY? C. ARE YOU AN INDIVIDUAL SHIPPING HOUSEHOLD GOODS OR PERSONAL EFFECTS? o o Click here for GBP form Click here for USD form Page 1 of 15
MARINE CARGO PROPOSAL FORM (INDIVIDUAL USE via Broker/Intermediary) This Proposal Form is only suitable for a private individual arranging cover for Marine Cargo Transit(s) where the individual has insurable interest. Please note that in completing this Proposal Form you must answer all questions fully and honestly. Failure to do so may mean that any claim is not paid or not paid in full. This proposal form is not suitable for private individuals insuring cargoes / goods in transit that fall into the following situations: 1) Household Goods 2) Motor Vehicles whilst under own power SECTION 1 The Proposer 1.1) Full name of the Insured (you) 1.2 ) Are you domiciled in the UK? (See Guidance Notes) Yes/No 1.3) Full risk address (inc. postcode) 1.4) Full postal address (inc. postcode) 1.5) Telephone No. / Fax No. SECTION 2 Cargo 2.1) Description of Cargo to be shipped 2.2) Size of Individual interest 2.3) Type of Packing Cartons Bundles Bulk Shipments Full Container Load Less than Container Load 2.4) Description of Packing, please specify 2.5) Cargo Details Containerized Door to Door 2.6) Are you going to be shipping (please An Individual Shipment (facultative) specify yes or no and follow the number) (Please fill number 3) Multiple Shipments (Open Cover) (Please fill number 4) SECTION 3 Individual Shipment Single Policy 3.1) Sum Insured 3.2) Voyage/Transit From: To: 3.3) Transshipment Port (if any) 3.4) Vessel s Name/Flight No. 3.5) Age of Vessel Page 2 of 15
3.6) Estimated Departure Date Please skip number 4 and go to number 5 SECTION 4 Multiple Shipments Open Cover 4.1) Mode of Transport Road Rail Sea Air 4.2) Maximum Sum Insured Per Shipment 4.3) Voyage/Transit From: To: 4.4) Transhipment Port (if any) 4.5) Estimated Annual Turnover 4.6) Frequency of Shipments Per Month SECTION 5 Coverage Required Institute Cargo Clauses (A) Institute Cargo Clauses (B) Institute War Clauses (Cargo) Institute Strike Clauses (Cargo) Others (please specify) SECTION 6 Standard Clauses The insurance is subject to the following clauses:- (a) Institute Radioactive Contamination Chemical Biological Bio-Chemical and Electromagnetic Weapons Exclusion Clause (b) Institute Classification Clause (c) Institute Cyber Attack Exclusion Clause (d) Cargo ISM Forwarding Charges (e) Cargo ISM Endorsement SECTION 7 Claims Experience (last 5 years) Claims Incurred ($) Year Premium Paid ($) Paid Outstanding Total I/We declare that the statements and particulars in this proposal are true and that I/We have not misstated or suppressed any information. I/ We understand that non-disclosure or misrepresentation of any information requested on this application will entitle the Insurer to cancel the insurance or not pay any claims in full. I/We undertake to inform insurers of any alteration to this information occurring before completion of the Contract of Insurance. I/We understand that signing this proposal form does not bind we/us to complete this insurance but agree that should a contract of insurance be conducted, this proposal and the statements made herein shall form the basis of the contract between me/us and the Insurer. I/We hereby consent to any information you have about me/us being processed by you for the purpose of providing insurance and claims handling which may necessitate you providing such information to third parties. Page 3 of 15
Signed: Date GUIDANCE NOTES: What is a UK Domicile Domicile is not the same as nationality. It refers to the country of residence for a continuous period of 2 years or more. Signature: You cannot be without a domicile, and you can only have one domicile at a time. Sums Insured In the event of transporting a Motor Vehicle, the Sum Insured must be the current market value of the vehicle at the destination. In the event of transporting all other cargoes, sum insured may be at invoice price (if new), or insured on the basis of Cost and Freight or Cost, Insurance and Freight (plus 10%). Note - If you require guidance on calculating sums insured, please speak to your insurance advisor or to a professional valuer. If sums insured are insufficient in the event of a loss, claim payments may be reduced. Page 4 of 15
MARINE CARGO PROPOSAL FORM (COMMERCIAL USE) This proposal form is not suitable for private individuals insuring cargoes / goods in transit that fall into the following situations: 3) Household Goods 4) Motor Vehicles whilst under own power Please note that in completing this Proposal Form you must disclose all material facts which may influence the acceptance or assessment of the risk. If you are in any doubt as to whether any facts are material, you should for your own protection disclose them, as failure to do so could invalidate the insurance. SECTION 1 The Proposer 1.1 Full Name, including trading name 1.2 ) Are you domiciled in the UK? 1.3) Full risk address (inc. postcode) 1.4) Full postal address (inc. postcode) 1.5) Telephone No. / Fax No. 1.7 Nature of Business (Please provide full description) 1.8 Number of Years in Business SECTION 2 Cargo 2.1 Description of Cargo to be shipped 2.2 Size of Individual interest 2.3 Type of Packing Cartons Bundles Bulk Shipments Full Container Load Less than Container Load 2.4 Description of Packing, please specify 2.5 Cargo Details Containerized Door to Door 2.6 Are you going to be shipping (please An Individual Shipment (facultative) specify yes or no and follow the number) (Please fill number 3) Multiple Shipments (Open Cover) (Please fill number 4) SECTION 3 Individual Shipment Single Policy 3.1 Sum Insured 3.2 Voyage/Transit From: To: 3.3 Transhipment Port (if any) Page 5 of 15
3.4 Vessel s Name/Flight No. 3.5 Age of Vessel 3.6 Estimated Departure Date Please skip number 4 and go to number 5 SECTION 4 Multiple Shipments Open Cover 4.1 Mode of Transport Road Rail Sea Air 4.2 Maximum Sum Insured Per Shipment 4.3 Voyage/Transit From: To: 4.4 Transhipment Port (if any) 4.5 Estimated Annual Turnover 4.6 Frequency of Shipments Per Month SECTION 5 Coverage Required Institute Cargo Clauses (A) Institute Cargo Clauses (B) Institute War Clauses (Cargo) Institute Strike Clauses (Cargo) Others (please specify) SECTION 6 Standard Clauses The insurance is subject to the following clauses:- (f) Institute Radioactive Contamination Chemical Biological Bio-Chemical and Electromagnetic Weapons Exclusion Clause (g) Institute Classification Clause (h) Institute Cyber Attack Exclusion Clause (i) Cargo ISM Forwarding Charges (j) Cargo ISM Endorsement SECTION 7 Claims Experience (last 5 years) Claims Incurred ($) Year Premium Paid ($) Paid Outstanding Total DECLARATION I/We declare that the statements and particulars in this proposal are true and that I/We have not misstated or suppressed any material facts. (N.B A material fact is one likely to influence the acceptance or assessment of this proposal by the Insurer. If you are in any doubt as to what constitutes a material fact you should consult your Insurer or your insurance advisor) I/ We understand that non-disclosure or misrepresentation of any material fact on this application will entitle the Page 6 of 15
Insurer to void the insurance. I/We undertake to inform insurers of any material alteration to these facts occurring before completion of the Contract of Insurance. I/We understand that signing this proposal form does not bind we/us to complete this insurance but agree that should a contract of insurance be conducted, this proposal and the statements made herein shall form the basis of the contract between me/us and the Insurer. I/We hereby consent to any information you have about me/us being processed by you for the purpose of providing insurance and claims handling which may necessitate you providing such information to third parties. Date: Signature: Page 7 of 15
HOUSEHOLD REMOVALS INSURANCE PROPOSAL FORM (GBP) This Proposal Form is only suitable for a private individual arranging cover for Household Goods in GBP where the individual has insurable interest. Please note that in completing this Proposal Form you must answer all questions fully and honestly. Failure to do so may mean that any claim is not paid or not paid in full. NAME AND ADDRESS OF PROPOSER (YOU) NAME AND ADDRESS OF REMOVER NAME OF PROFESSIONAL PACKER Please state if owner packed VOYAGE: ADDRESS FROM WHICH GOODS ARE TO BE MOVED ADDRESS TO WHICH GOODS ARE TO BE SENT IF EXACT ADDRESS IS NOT KNOWN STATE DESTINATION HAVE GOODS BEEN IN STORE SINCE PACKAGING FOR EXPORT? IF SO SINCE WHEN? WILL GOODS BE STORED AT DESTINATION? IF SO HOW LONG? METHOD OF TRANSIT If through Road Vehicle (a) Part Load (b) Full Load Sea and/or Rail Only (ex Road Transit) Air (i) (ii) THE FULL REPLACEMENT VALUE OF THE GOODS AT DESTINATION MUST BE INSURED; ANY ITEM VALUED OVER 150.00 MUST BE DECLARED SEPARATELY IN THE SCHEDULE BELOW AND THE VALUE STATE, i.e, ANTIQUE TABLE US 800, PIANO US 1,000. ITEMS NOT DECLARED WILL BE DEEMED TO HAVE A VALUE NOT GREATER THAN 150.00; (iii) IN THE EVENT OF LOSS OR DAMAGE BEING SUSTAINED FULL DETAILS OF THE CLAIM MUST BE NOTIFIED TO UNDERWRITERS AND/OR THEIR AGENTS WHTIHIN 30 DAYS O FTHE RECEIPT OF GOODS. No. Category Items valued over GBP 150.00 must be detailed below showing individual value of each item Total Value inc items over GBP 150.00 Page 8 of 15
1 Antique furniture: Piano: Musical instruments: Grandfather clock: 2 China: Glassware: Earthenware: Mirrors: Ornaments: Clocks: Lampshades: Marble goods: 3 Typewriters: Record players: Radio & television sets: Tape recorders: Records: Cameras: Projectors: Photographic & ancillary equipment: 4 Gas & electrical household appliances: Sewing machine: 5 Lounge & dining room furniture: 6 Bedroom furniture & mattresses: 7 Kitchen, bathroom & hall furniture: 8 Kitchen utensils (not glass, earthenware or electrical items): GBP... Total Value of categories 1-8 No. Category Items valued over GBP 150.00 must be detailed below showing individual value of each item Total Value inc items over GBP 150.00 9 Silver & cutlery: Page 9 of 15
10 Curtains: Cushions: Table linen & towels: Bed linen: 11 Pictures: 13 Carpets & rugs: 14 Toys: Games: Books: 15 Garden & other tools: Garden Furniture: Bicycles: Sports equipment: 16 Other items: 17 Freight: Total Value of categories 9-17 GBP... Plus total value of categories 1-8 GBP... Total value to be insured GBP... IMPORTANT: Replacement values overseas are often far greater than in place of Domicile and claims will only be recoverable in full if replacement values at DESTINATION are insured in respect of the whole consignment. I/We declare that the statements and particulars in this proposal are true and that I/We have not misstated or suppressed any information. I/ We understand that non-disclosure or misrepresentation of any information requested on this application will entitle the Insurer to cancel the insurance or not pay any claims in full. I/We undertake to inform insurers of any alteration to this information occurring before completion of the Contract of Insurance. I/We understand that signing this proposal form does not bind we/us to complete this insurance but agree that should a contract of insurance be conducted, this proposal and the statements made herein shall form the basis of the contract between me/us and the Insurer. I/We hereby consent to any information you have about me/us being processed by you for the purpose of providing insurance and claims handling which may necessitate you providing such information to third parties. Signed: Date GUIDANCE NOTES: What is a UK Domicile Page 10 of 15
Domicile is not the same as nationality. It refers to the country of residence for a continuous period of 2 years or more. You cannot be without a domicile, and you can only have one domicile at a time. Sums Insured In the event of transporting a Motor Vehicle, the Sum Insured must be the current market value of the vehicle at the destination. In the event of transporting all other cargoes, sum insured may be at invoice price (if new), or insured on the basis of Cost and Freight or Cost, Insurance and Freight (plus 10%). Note - If you require guidance on calculating sums insured, please speak to your insurance advisor or to a professional valuer. If sums insured are insufficient in the event of a loss, claim payments may be reduced HOUSEHOLD AND/OR PERSONAL EFFECTS CONDITIONS. This Insurance is subject to The Institute Cargo Clauses "A" and The Institute War Clauses, and Institute Strikes Clauses and in addition to the following clauses, conditions and exclusions:- 1. AVERAGE CLAUSE. This policy is subject to the Conditions of Average, that is to say if the property covered by this Insurance shall at the time of loss be of greater value than the Sum Insured hereby the Assured shall only be entitled to recover hereunder such proportion of the said loss as the Sum Insured by this policy bears to the Total Value of the said Property. 2. PAIRS AND SETS CLAUSE. Where any Insured item consist of articles in a pair or set this policy is not to pay more than the value of any particular part or parts which may be lost without reference to any special value which such article or articles may have as part of such pair or set, nor more than a proportionate part of such pair or set. 3. DEPRECIATION. Insurers liability is restricted to the reasonable cost of repair and no claim is to attach hereto for depreciation consequent thereon. 4. MECHANICAL AND ELECTRICAL DERANGEMENT. Excluding loss or damage due to mechanical, electrical or electronic derangement unless there is evidence of external damage to the insured item or its packing. 5. Excluding loss or damage due to moth, vermin, wear, tear, and gradual deterioration. 6. REPLACEMENT CLAUSE. In the event of loss of or damage to any part or parts of an insured machine caused by a peril covered by the policy, the sum recoverable shall not exceed the cost of replacement or repair of such part or parts plus charges for forwarding and refitting, if incurred, but excluding duty unless the full duty is included in the amount insured, in which case loss, if any, sustained by payment of additional duty shall also be recoverable. Provided always that in no case shall the liability of Insurers exceed the insured value of the complete machine. 7. CLIMATIC CONDITIONS CLAUSE. Excluding loss or damage by climatic or atmospheric conditions or extremes of temperature. 8. OWNER PACKED EFFECTS. Excluding breakage, scratching, denting, chipping, staining, and tearing of owner packed effects, including trunks, suitcases, and the like. Also Excluding claims for missing items unless a valued list of contents is supplied by owner prior to commence-ment of transit. 9. EXCLUDED GOODS. Excluding loss of and or damage to furs valued over GBP 150.00 or any cash, notes, stamps, deeds, tickets, travellers cheques, jewellery, watches, or similar valuable articles. Page 11 of 15
HOUSEHOLD REMOVALS INSURANCE PROPOSAL FORM (USD) This Proposal Form is only suitable for a private individual arranging cover for Household Goods in USD where the individual has insurable interest. Please note that in completing this Proposal Form you must answer all questions fully and honestly. Failure to do so may mean that any claim is not paid or not paid in full. NAME AND ADDRESS OF PROPOSER (YOU) NAME AND ADDRESS OF REMOVER NAME OF PROFESSIONAL PACKER Please state if owner packed VOYAGE: ADDRESS FROM WHICH GOODS ARE TO BE MOVED ADDRESS TO WHICH GOODS ARE TO BE SENT IF EXACT ADDRESS IS NOT KNOWN STATE DESTINATION HAVE GOODS BEEN IN STORE SINCE PACKAGING FOR EXPORT? IF SO SINCE WHEN? WILL GOODS BE STORED AT DESTINATION? IF SO HOW LONG? METHOD OF TRANSIT If through Road Vehicle (a) Part Load (b) Full Load Sea and/or Rail Only (ex Road Transit) Air (i) (ii) THE FULL REPLACEMENT VALUE OF THE GOODS AT DESTINATION MUST BE INSURED; ANY ITEM VALUED OVER $250.00 MUST BE DECLARED SEPARATELY IN THE SCHEDULE BELOW AND THE VALUE STATE, i.e, ANTIQUE TABLE USD 800, PIANO USD 1,000. ITEMS NOT DECLARED WILL BE DEEMED TO HAVE A VALUE NOT GREATER THAN $ 250.00; (iii) IN THE EVENT OF LOSS OR DAMAGE BEING SUSTAINED FULL DETAILS OF THE CLAIM MUST BE NOTIFIED TO UNDERWRITERS AND/OR THEIR AGENTS WHTIHIN 30 DAYS O FTHE RECEIPT OF GOODS. No. Category Items valued over $ 250.00 must be detailed below showing individual value of each item Total Value inc items over $ 250.00 Page 12 of 15
1 Antique furniture: Piano: Musical instruments: Grandfather clock: 2 China: Glassware: Earthenware: Mirrors: Ornaments: Clocks: Lampshades: Marble goods: 3 Typewriters: Record players: Radio & television sets: Tape recorders: Records: Cameras: Projectors: Photographic & ancillary equipment: 4 Gas & electrical household appliances: Sewing machine: 5 Lounge & dining room furniture: 6 Bedroom furniture & mattresses: 7 Kitchen, bathroom & hall furniture: 8 Kitchen utensils (not glass, earthenware or electrical items): Total Value of categories 1-8 USD... No. Category Items valued over $ 250.00 must be detailed below showing individual value of each item Total Value inc items over $ 250.00 9 Silver & cutlery: Page 13 of 15
10 Curtains: Cushions: Table linen & towels: Bed linen: 11 Pictures: 13 Carpets & rugs: 14 Toys: Games: Books: 15 Garden & other tools: Garden Furniture: Bicycles: Sports equipment: 16 Other items: 17 Freight: Total Value of categories 9-17 USD... Plus total value of categories 1-8 USD... Total value to be insured USD... IMPORTANT: Replacement values overseas are often far greater than in place of Domicile and claims will only be recoverable in full if replacement values at DESTINATION are insured in respect of the whole consignment. I/We declare that the statements and particulars in this proposal are true and that I/We have not misstated or suppressed any information. I/ We understand that non-disclosure or misrepresentation of any information requested on this application will entitle the Insurer to cancel the insurance or not pay any claims in full. I/We undertake to inform insurers of any alteration to this information occurring before completion of the Contract of Insurance. I/We understand that signing this proposal form does not bind we/us to complete this insurance but agree that should a contract of insurance be conducted, this proposal and the statements made herein shall form the basis of the contract between me/us and the Insurer. I/We hereby consent to any information you have about me/us being processed by you for the purpose of providing insurance and claims handling which may necessitate you providing such information to third parties. Signed: Date GUIDANCE NOTES: What is a UK Domicile Domicile is not the same as nationality. It refers to the country of residence for a continuous period of 2 years or more. Page 14 of 15
You cannot be without a domicile, and you can only have one domicile at a time. Sums Insured In the event of transporting a Motor Vehicle, the Sum Insured must be the current market value of the vehicle at the destination. In the event of transporting all other cargoes, sum insured may be at invoice price (if new), or insured on the basis of Cost and Freight or Cost, Insurance and Freight (plus 10%). Note - If you require guidance on calculating sums insured, please speak to your insurance advisor or to a professional valuer. If sums insured are insufficient in the event of a loss, claim payments may be reduced HOUSEHOLD AND/OR PERSONAL EFFECTS CONDITIONS. This Insurance is subject to The Institute Cargo Clauses "A" and The Institute War Clauses, and Institute Strikes Clauses and in addition to the following clauses, conditions and exclusions:- 1. AVERAGE CLAUSE. This policy is subject to the Conditions of Average, that is to say if the property covered by this Insurance shall at the time of loss be of greater value than the Sum Insured hereby the Assured shall only be entitled to recover hereunder such proportion of the said loss as the Sum Insured by this policy bears to the Total Value of the said Property. 2. PAIRS AND SETS CLAUSE. Where any Insured item consist of articles in a pair or set this policy is not to pay more than the value of any particular part or parts which may be lost without reference to any special value which such article or articles may have as part of such pair or set, nor more than a proportionate part of such pair or set. 3. DEPRECIATION. Insurers liability is restricted to the reasonable cost of repair and no claim is to attach hereto for depreciation consequent thereon. 4. MECHANICAL AND ELECTRICAL DERANGEMENT. Excluding loss or damage due to mechanical, electrical or electronic derangement unless there is evidence of external damage to the insured item or its packing. 5. Excluding loss or damage due to moth, vermin, wear, tear, and gradual deterioration. 6. REPLACEMENT CLAUSE. In the event of loss of or damage to any part or parts of an insured machine caused by a peril covered by the policy, the sum recoverable shall not exceed the cost of replacement or repair of such part or parts plus charges for forwarding and refitting, if incurred, but excluding duty unless the full duty is included in the amount insured, in which case loss, if any, sustained by payment of additional duty shall also be recoverable. Provided always that in no case shall the liability of Insurers exceed the insured value of the complete machine. 7. CLIMATIC CONDITIONS CLAUSE. Excluding loss or damage by climatic or atmospheric conditions or extremes of temperature. 8. OWNER PACKED EFFECTS. Excluding breakage, scratching, denting, chipping, staining, and tearing of owner packed effects, including trunks, suitcases, and the like. Also Excluding claims for missing items unless a valued list of contents is supplied by owner prior to commence-ment of transit. 9. EXCLUDED GOODS. Excluding loss of and or damage to furs valued over USD 200.00 or any cash, notes, stamps, deeds, tickets, travellers cheques, jewellery, watches, or similar valuable articles. Page 15 of 15