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Forenames
Surname
Address
Zip/Postcode
Email Address
Tel (Work)
Tel (Mobile)
No Yes Is the cargo containerised?
Please give the direction of the shipment
Europe Africa Asia Europe Oceania Middle East United States South America Shipment From
Africa Asia Europe Oceania Middle East United States South America Shipment To
Name of Shipping Line
Comodity Type
New Used Reconditioned Condition of Comodity
No Yes Containerised
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Shipment Value in Euros
+ % c & F
Total
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I declare that to the best of my knowledge and belief, the information given to you on this form is true in every respect. I also declare that if anything on this form was entered by another person, he/she acted as my agent for this purpose. I agree that this proposal and declaration shall be the basis of the Contract between me and the Company.
Note: Submitting this form does not bind the proposer to complete this insurance.
The Company reserves the right to decline any proposal.
The Proposer should keep a record of all information supplied to the Insurer for the purpose of entering into the Contract, and a copy of this Proposal will be supplied on request, within a period of three months after completion.
Edward William Marine Services SL is a Spanish Registered Insurance Agent and as such is not authorised or Regulated by the UK Financial Services Association and is not covered for compensation under the UK Financial Services Compensation Scheme (FSCS)
