Company Name (required)
Brokerage MC#(required)
Are You A Freight Forwarder? (required) YesNo
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? YesNo
If so, with whom?:
In the past 3 years, have you been named in any lawsuit?: YesNo
If lawsuit, please explain (Text):
In the past 3 years, have any claims been paid on your behalf?: YesNo
If claims paid on your behalf, please explain (Text):