Legal Liability / E&O Policy Applicationadmin2021-04-25T17:31:47-05:00 1. General InformationCompany Name* Company Address* Contact Person* Phone*Email* Years in Business* No. of Employees* Policy Effective Date* DD slash MM slash YYYY Please list all associations/organizations for which your Company holds membership:2. Loss ControlDo you employ a Safety Officer or Risk Manager? Please provide name and years of experience.* Is there any loss prevention/control program for employees? Please provide training requirements.* 3. Company Operations & ServiceServices Provided Does your company offer All Risk Cargo (shippers’ interest) through your Insurance Carrier? Freight Forwarder/Transportation Broker Customs House Broker NVOCC Indirect Air Carrier Motor Truck Carrier Warehousing Services Current Policies Shippers Interest Cargo (Ocean, Inland and Air) Warehouse/Storage (Goods of Others) Freight Forwarders Legal (Contingent Cargo Legal) Freight Forwarders Errors & Omissions Carriers Legal (MTCLL, NVOCC & Indirect Air) Warehouse Legal Liability Warehousing Services Current Insurance Carrier:* Please indicate the percentage per transportation conveyance commonly used by the Company (approximate):Ocean Cargo % International Air % Domestic Truck % Domestic Rail % Domestic Air % Foreign Truck/Rail % Percentage of Shipments as Carrier (Principal) % Percentage of Shipments as Broker % Percentage of Shipments Containerized % Percentage of Shipments in Bulk % Please indicate percentage per type of cargo (approximate):General Cargo % Electronic & Electronic Equipment % Temperature Controlled/Perishables % Machinery & Equipment % Dry Bulk % Wet Buk % Oversize Cargo % Chemicals & Hazardous Materials % Geographical ScopeUSA & Canada % China/Japan % Mexico % South East Asia % Central/South America % India/Pakistan % Europe % Middle East % 4. Transportation and VolumeGross Freight Receipts (Total Gross Sales Less Taxes)Last 12 MonthsNext 12 Months (estimated)Percentage of Receipts as Broker/Agent % Percentage of Receipts as Motor Truck Carrier % Percentage of Receipts as NVOCC % Percentage of Receipts as Indirect Air Carrier % Percentage of Receipts as Warehousemen % Ocean ShipmentsDo you Issue In-House Bills of Lading Yes No (Copy must be attached)Attach fileMax. file size: 512 MB.Do you have contracts in place with any shipper holding you liable beyond specified on your Bill of Lading? Yes No Copy must be attachedAttach fileMax. file size: 512 MB.Percentage of shipments under your own Bill of Lading % Air ShipmentsDo you Issue In-House Air Waybill Yes No (Copy must be attached)Attach fileMax. file size: 512 MB.Do you have contracts in place with any shipper holding you liable beyond specified on your Air Waybill? Yes No (Copy must be attached)Attach fileMax. file size: 512 MB.Percentage of shipments under your own Air Waybill % Truck/Rail ShipmentsDo you Issue Truck/Rail Bills of Lading or Freight Receipt Yes No (Copy must be attached)Attach fileMax. file size: 512 MB.Do you have contracts in place with any shipper holding you liable beyond specified on your Truck/Rail Bill of Lading? Yes No (Copy must be attached)Attach fileMax. file size: 512 MB.Percentage of shipments under your own Bill of Lading % WarehousingDo you own or operate Warehouses for third party storage? Yes No Do you provide your own Warehouse Receipt? Yes No (Copy must be attached)Attach fileMax. file size: 512 MB.Do you provide open storage facilities? Yes No Do you provide refrigerated storage facilities? Yes No Do you have contracts in place with any client holding you liable beyond specified on your Warehouse Receipt? Yes No (Copy must be attached)Attach fileMax. file size: 512 MB.Provide list of locations, construction, fire and security information as well as maximum values at any given timePlease indicate maximum value per shipment for:Ocean Cargo Shipments $Air Cargo Shipments $Truck/Rail Cargo Shipments $House Hold Goods Shipments $Temperature Controlled/Perishables Shipments $5. Limits and DeductiblesPlease indicate current coverage limits:Ocean Cargo Shippers Interest (All Risk) $Inland Transit Shippers Interest (All Risk) $Warehouse All Risk (Goods of Others) $Please Include Statement of ValuesAir Cargo Shippers Interest (All Risk)Ocean Cargo Shipments (NVOCC) $Air Cargo Shipments (Indirect Air Carrier) $Motor Truck Shipments (Motor Truck Cargo Legal) $Freight Forwarders Legal (Contingent Cargo Legal) $Freight Forwarders Errors & Omissions $Warehouse Legal Liability $Please Include Location List and Limits.Please indicate current deductibles per coverage:Ocean Cargo Shippers Interest (All Risk) $ Inland Transit Shippers Interest (All Risk) $ Warehouse All Risk (Goods of Others) $ Carriers Legal Liability $ Freight Forwarders Legal (Contingent Cargo Legal) $ Freight Forwarders Errors & Omissions $ Warehouse Legal Liability $ Air Cargo Shippers Interest (All Risk)6. Loss History (5 years)Claim YearYear PremiumShippers Interest Total PaidCarriers Legal Total PaidForwarders Legal Total PaidE&O Total PaidWarehouse Legal Total Paid
