Address of Applicant:Yrs. in Business

/ APPLICATION FOR CARGO INSURANCE - SEAFOOD
SHOREPOINT INSURANCE SERVICES
1120 BRISTOL STREETCOSTA MESA, CA92626
800-350-5647 / 714-430-0035 / FAX: 714-430-0036
CA LICENSE 0K07568

NAME OF APPLICANT: DATE:

ADDRESS OF APPLICANT:YRS. IN BUSINESS:

APPLICANT CONTACT: TELEPHONE: FAX:

APPLICANT E-MAIL/WEB:

DESCRIBE NATURE OF APPLICANT’S BUSINESS (Processor, Distributor, Commodity Broker, Retailer, etc.)

GEOGRAPHICAL LIMITS
U.S. TO WORLD / WORLD TO U.S. / WORLD TO WORLD / OTHER:
VALUATION
FOR GOODS SOLD, NOT DELIVERED: SELLING PRICE
FOR GOODS NOT SOLD: AMOUNT OF INVOICE, INCLUDING CHARGES, PLUS OCEAN FREIGHT, PLUS 10%
OTHER:

PRINCIPAL SEAFOOD TO BE INSURED

PRODUCT CATEGORIES

FRESHFROZENCANNEDSMOKED/CURED BREADED/PREPARED LIVE OTHER

PACKING - DESCRIBE IN DETAIL

INSURING CONDITIONS
AUTOMATICALLY INCLUDED: ALL RISKS OF PHYSICAL LOSS OR DAMAGE FROM ANY EXTERNAL CAUSE. WAREHOUSE-TO-WAREHOUSE CLAUSE. WAR RISKS, STRIKES, RIOTS & CIVIL COMMOTION. TRANSSHIPMENTS AND 30 DAYS FOR CONSOLIDATION/DECONSOLIDATION. U.S. IMPORT DUTY. ALL RISK INCLUDING SPOILAGE OR DETERIORATION RESULTING FROM IMPROPER TEMPERATURE FOR PERISHABLE COMMODITIES. USFDA REJECTION REQUIRED: YES NO
EXCEPTION TO ALL RISK CONDITIONS:
LIMITS OF INSURANCE
$ 1,000,000 / BY ANY ONE VESSEL
$ 1,000,000 / BY ANY ONE AIRCRAFT
$ 500,000 / BY ANY ONE DOMESTIC CONVEYANCE (AIR/TRUCK/RAIL)
$ 500,000 / BY ANY ONE BARGE
$ 500,000 / BY PARCEL POST (U.S. MAIL)
$ 500,000 / AT ANY ONE STORAGE LOCATION
$ 1,000,000 / AGGREGATE STORAGE LOCATION FOR EARTHQUAKE, FLOOD, NAMED WIND PERIL
$ 250,000 / USFDA REJECTION EACH B/L OR ENTRY
$500,000
$500,000 / USFDA REJECTION AGGREGATE
LACEY ACT PER CLAIM
EXCEPTION TO LIMITS:

PAGE TWO

CARGO INSURANCE APPLICANT:

GROSS INSURED VOLUME & SALES

EXPORT INSURED

VOLUME

IMPORT INSURED

VOLUME

DOMESTIC INSURED VOLUME

/ TOTAL ANNUAL SALES
PAST 12 MONTHS / $ / $ / $ / $
EST. NEXT 12 MONTHS / $ / $ / $ / $
EST. AVG. VALUE PER SHIPMENT / $ / $ / $
CONVEYANCE TYPE % / Vsl / Air / Vsl / Air / Air / Trk
WHAT % VOLUME AT INSURED’S RISK? / % / % / %

PRINCIPAL COUNTRIES TO WHICH GOODS ARE EXPORTED (indicate % involved)

PRINCIPAL COUNTRIES FROM WHICH GOODS ARE IMPORTED (indicate % involved)

CURRENT/EXPIRING POLICY INFORMATION

CURRENT INSURER: BROKER:

CURRENT PREMIUM RATE: % ESTIMATED ANNUAL PREMIUM: $

LOSS INFORMATION (3-Year History. Include Countries, Amount, Loss Description, Recovery if any)
WAREHOUSING
ADDRESS / DESCRIPTION (Own,Public,Etc.) / LIMIT / AVERAGE
SelectBlockBrickConcreteFrameMetalStructure Steel
SelectSprinkleredNon-Sprinklered / $ / $
SelectBlockBrickConcreteFrameMetalStructure Steel
SelectSprinkleredNon-Sprinklered / $ / $
3. / SelectBlockBrickConcreteFrameMetalStructure Steel
SelectSprinkleredNon-Sprinklered / $ / $
4. / SelectBlockBrickConcreteFrameMetalStructure Steel
SelectSprinkleredNon-Sprinklered / $ / $
5. / SelectBlockBrickConcreteFrameMetalStructure Steel
SelectSprinkleredNon-Sprinklered / $ / $

Include additional locations on a separate page.

IF U.S. IMPORTER, OVERSEAS SUPPLIER* LOCATIONS (Include Name & City/Country Address)

NAME / ADDRESS
1. / 1.
2. / 2.
3. / 3.
4. / 4.
5. / 5.
6. / 6.
*If USFDA Rejection coverage is desired, list of suppliers is required. Include add’l suppliers on a separate page.

REMARKS:

NAME: / TITLE: / DATE: