Contingent Cargo Application Form 1

    Company Name (required)

    Brokerage MC#(required)

    Are You A Freight Forwarder? (required)

    If Yes, Provide FF#

    Contact Name (required)

    Mailing Address (required)

    Telephone (required)

    Fax (required)

    Email (required)

    Proposed Effective Date (mm/dd/yy)

    How Many Years in Business?

    Have you ever had Contingent Cargo Insurance?

    If so, with whom?:

    In the past 3 years, have you been named in any lawsuit?:

    If lawsuit, please explain (Text):

    In the past 3 years, have any claims been paid on your behalf?:

    If claims paid on your behalf, please explain (Text):