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Proposer's Name *

Contact No

Email *

Address *

Broker/Agent *

Copies Required:

Name of L/C Opening Bank *

Description of Cargo *

Marks & Nos

Packing *

Invoice No *

Voyage *

From :
Via :
To :

Mode of Conveyance

Including

Transshipment
Part Shipment
Land Transits

Name of Vessel/
Flight Details

Date of Sailing/
Despatch:

(dd/mm/yyyy)

Shipment Method
(if by sea freight)

ON DECK
FCL/FCL
LCL

UNDER DECK
FCL/LCL
BULK

Cover Required: Institute Cargo Clauses

A AIR	B WAR	C STRIKES	OTHERS
If it is 'Other':

Claims Payable at

Colombo Destination

L/C Requirement

Value

FOB CIF C&F(CFR)	*
If Currency is 'Other' please specify:
Extra(+) %
Total
VAT %

Other Comments/
Instructions

* Please refrain from entering commas, spaces etc in between.

I/ We confirm that the above statements made by me/us or on my/our behalf are true to the best of my/our knowledge and belief.

Non disclosure or misrepresentation of material facts could invalidate the insurance contract. Material facts are those facts, which would influence the acceptance or assessment of the proposal. If you are in doubt as to whether a fact is material you should disclose it.

* Required Information