CARGO LIABILITY INSURANCE

Confidential Proposal Form

  • This form may be completed by your authorised insurance broker
  • Please attach any relevant company literature which may assist us with your enquiry
  • If you have insufficient space to answer any questions, please attach a separate sheet

Details of the Applicant

Company Name:
Company Address:
E-mail: Telephone:
Website: Date Established:
Have you obtained quality assurance accreditation from any nationally recognisedorganisation? If “yes”, please specify:
Please detail names of any trade associations to which you are affiliated or are members:
Names and addresses of any subsidiary, affiliated and associated companies or locations which you wish to include in the insurance:

Details of the Key Personnel

Please list your directors or partners, noting their professional qualifications or number of years experience:
Number of Directors, Partners or Senior Managers:
Number of Clerical Staff:
Number of Manual Staff:
Total Number of Employees:

Financial details

Gross Freight Receipts (GFR) Gross revenue including payments to agents and subcontractors in respect of transport services, but excluding customs duty, sales tax, or similar fiscal charges paid on behalf of Customers.

Please state your GFR for the previous 12 months:Currency = ………………
Please state your GFR forecast for the next 12 months:
Service /  / No. of years experience / Approximate % of annual GFR
Ocean freight forwarder
Non Vessel Owning/Operating Common Carrier (NVOCC)
Freight Forwarding Agent (cargo is not under your care, custody and control)
Air freight forwarder/air cargo agent
Road haulier (please complete Appendix 2)
In-transit warehousing (please complete Appendix 1)
Short, medium and long term warehousing (please completed Appendix 1)
Packing/ consolidating (please complete Appendix 1)
Other (please detail)
What percentage of your annual GFR is paid to sub-contractors in the following services:
Road Hauliers / % / Warehouseman / % / Consolidators/ Packers / % / NONE
Do you contract on a back to back basis with sub-contractors?
(i.e. is the subcontractor required to comply with all relevant obligations of the main contract you operate under with your customer). / YES / NO

Cargo details

What percentage of your annual GFR results from carriage of cargo which is:
Break-bulk / % / If so, detail approximate tonnage:
Containerised / % / If so, detail approximate TEU’s:
Palletised / % / If so, detail approximate tonnage:
Please estimate the percentage of your annual traffic to, from or within each of the following areas:
Western Europe / % / Eastern Europe / %
Southern Africa / % / Rest of Africa* / %
Middle East* / % / Far East* / %
Central / South America / % / USA / Canada / %
Australasia / % / Indian Sub-Continent / %
Russia* / % / Other* / %
*Please attach further details if you are providing services to, from or within the Middle East, Russia, Africa, the Far East or any other area that is not specifically noted above. Galleon's Territorial Limits are Worldwide but excluding any Accident, situation or suit in or arising from Burma, Iran, Iraq, Yemen, Afghanistan, Pakistan, Somalia, Syria, North Korea or the regions of Luhansk and Donetsk.
Please indicate what percentage of your annual GFR is represented by: / General Cargo / %
Refrigerated Cargoes / % / Tobacco Products / %
Tank Containers / % / Project Cargoes / %
Spirits / % / Dangerous Cargoes / %
High Value Goods* / % / Arms & Ammunition / %
Other(please detail)
*(e.g. cash, computers, jewellery, cameras, TVs, audio equipment, mobile phones)

Transport Documents/Trading Conditions

Please indicate which documents and business conditions you are currently using:
FIATA B/L / YES / NO / House Airwaybill(please attach) / YES / NO
Own House B/L (please attach) / YES / NO / Master Airwaybill(please attach) / YES / NO
CMR / CIM Consignment Note / YES / NO / Warehousing Conditions / YES / NO
National Association Conditions / YES / NO / Own Conditions (please attach) / YES / NO
No Contract / YES / NO / Other (please attach) / YES / NO
What percentage of the Bills of Ladings issued per annum are “electronic”? / % / N/A

Insurance Details

Have any claims been made against you, or have there been any circumstances that may give rise to a claim being made against you, in the last 5 years?
If “yes”, please provide details on a separate sheet / YES / NO
Has any Insurer ever declined to insure you? / YES / NO
Has any Insurer ever cancelled your insurance? / YES / NO
Has any Insurer refused to renew your insurance? / YES / NO
Has any Insurer previously imposed any special policy terms, conditions or exclusions? If “yes”, please provide details on a separate sheet / YES / NO
Are you currently insured for liability risks? / YES / NO
If “yes”, by whom and what is your policy renewal date, current limit, deductible and premium?

Appendix 1: Warehousing and/or Packing and Consolidating Facilities

Please detail the age, size, structure and location of the warehouse(s), (if additional space is required please attach a separate sheet).
Do you own or lease the warehouse? / OWN / LEASE
Is the warehouse insured for physical loss & damage risks and are you a Named Insured on the policy? / YES / NO
Is the warehouse TAPA (or other similar body) certified? / YES / NO
When was the facility last surveyed? Please attach a copy / YES / NO

Cargo

What cargo do you store?
What is your responsibility for the cargo stored/handled?
Do you store cargo for more than 3 months at a time? If so, please provide details on a separate sheet
Please provide an estimated average and maximum value of goods stored at any one time: (please include the currency) / Max:
Avg:
What % of your total revenue is generated by warehousing operations?

Fire Prevention

Do all warehouses have sprinklers and fire detection systems? / YES / NO
Is there easy access throughout the facility to the mains water supply? / YES / NO
Is there easy access to an emergency pump or suitable reserve power supply? / YES / NO

Security

Do your security precautions include 24 hour security guards? / YES / NO
Are all the building, perimeter fences and gates always alarmed? / YES / NO
Do your security precautions include CCTV? / YES / NO
Are security checks continually documented? / YES / NO
Please detail any other security precautions taken:

Risk Mangement

Do you have a property and equipment maintenance programme? / YES / NO
Do you have a staff training programme? / YES / NO
Are you compliant with the International Ship & Port Security Code (ISPS Code)?(if applicable) / YES / NO

Appendix 2: Road Haulage

Do you subcontract this service? If ‘’yes’’ please indicate the percentage…………………% / YES / NO
Do you own or lease the vechiles? / OWN / LEASE
Please detail the number and details of vehicles owned/leased: (if additional space is required please attach a separate sheet).
Please detail your security measures including whether they are TAPA (or other similar body) certified?
Please detail the delivery radius and/or route:
Please indicate what percentage of your annual GFR is represented by:
Refrigerated Cargoes / % / Tobacco Products / %
Tank Containers / % / Project Cargoes / %
Spirits / % / Dangerous Cargoes / %
High Value Goods* / % / General Cargo / %
Other(please detail)

Declaration and Signature

You must make a fair presentation of the risk to the Insurer, in accordance with Section 3 of the Insurance Act 2015. In summary, you must:

a)Disclose to the Insurer every material circumstance which you know or ought to know. Failing that, you must give the Insurer sufficient information to put a prudent insurer on notice that it needs to make further enquiries in order to reveal material circumstances. A matter is material if it would influence the judgement of a prudent insurer as to whether to accept the risk, or the terms of the insurance (including premium); and

b)Make the disclosure in clause (a) above in a reasonably clear and accessible way; and

c)Ensure that every material representation of fact is substantially correct, and that every material representation of expectation or belief is made in good faith.

For the purposes of making a fair presentation of the risk to the Insurer, you are expected to know the following:

a)If you are an individual, what is known to you and anybody who is responsible for arranging your insurance

b)If you are not an individual, what is known to anybody who is part of your senior management; or anybody who is responsible for arranging your insurance

c)Whether you are an individual or not, what should reasonably have been revealed by a reasonable search of information available to you. The information may be held within your organisation, or by any third party (including but not limited to subsidiaries, affiliates, the broker, or any other person who will be covered under the insurance). If you are insuring subsidiaries, affiliates or other parties, the Insurer expects that you will have included them in its enquiries, and that you will inform the Insurer if it has not done so. The reasonable search may be conducted by making enquiries or by any other means.

We declare that the information and answers given in this form are true to the best of our knowledge and belief and that we have not misstated, misrepresented or suppressed any material facts that might influence the assessment of the risk. At any time during the Period of Insurance, if conditions, exposures or circumstances materially increase to that declared herein, we understand we are immediately required to advise Underwriters. We also understand that completion of this form does not bind Underwriters or mean we will accept the Insurance Contract but, if terms are agreed, it will form part of the Insurance Contract. By completing this proposal form we confirm that any business we conduct with Galleon is in accordance with all relevant anti-money laundering, anti-financial crime and international economic or financial sanctions legislations.

Our policy and procedures comply with all known legislation involving the collection, use, storage and disclosure of personal information. You are entitled to access the information we hold concerning you and we can supply a copy of our full policy and procedures on request. We and our agents need to collect, use and disclose your information in order to consider your application for insurance and provide the cover you have selected, administer your policy and handle any claim. This may involve disclosing your information to third parties who assist in providing such services. If you provide information concerning another person who you represent, e.g. as their broker or agent, you are confirming that you have made them aware that their information is being disclosed to us and that you have their authority to do so. By supplying personal information to us you are confirming that you have understood the above and that it meets with your approval

Signed:Position:

Name:Date:

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