Special Request Form
Date    
Company Name/Location    
Policy No.    
Contact Name    
*Phone Number    
*Fax Number    
*Email Address    
Name of Actual Shipper (Exporter/Importer) to be covered    
Product Description (include any information about special conditions)    
Packing, number of cartons, master boxes, less than full container, etc. PLEASE NOTE: FOR FRAGILE ITEMS, FULL DETAILS OF PACKING ARE ESSENTIAL TO MAXIMIZE CHANCE FOR BEST RATE AND COVERAGE.    
Mode of Shipment
Air   Ocean   
Truck   Other 
     
Shipper's experience with product    
Indicate if single or repeat shipments, and number of shipments

Single   Multiple 
Number of shipments expected 
  
 Value of shipments in US Dollars    
 Average $    
 Maximum $    
 Total Estimated Annual $    
 From:    
 To:    
 Loss History in last three year