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					                                                                                      APPLICATION
                Chubb Insurance Company of Canada                                     Open Ocean Cargo Policy



                            By completing this APPLICATION you are applying for coverage with
                                  Chubb Insurance Company of Canada (the "Company")


Applicant’s Name:
Applicant’s Address:
Phone:     (      )                                                Fax:     (     )
E-mail address and/or Web site address:
Applicant is:         Manufacturer      Importer    Consumer       Broker       Freight Forwarder
                      Purchasing Agent      Other – Describe:
Does Applicant have other divisions, subsidiaries or affiliates?                                                Yes     No
If yes, state name, location and whether or not they are to be insured:


BACKGROUND
Present Underwriter:
Present Agent/Broker:
Estimated Annual Dollar Volume of Goods shipped:        $
Percent now insured by Applicant:                                      %


FIVE YEARS EXPERIENCE
                                                            *Paid Marine Losses            *Outstanding Marine Losses
                 Amount           Gross Amount         No. of                              No. of
 Year            Insured         Marine Premium        Losses          Total Amount        Losses        Total Amount

           $                     $                                 $                                 $
           $                     $                                 $                                 $
           $                     $                                 $                                 $
           $                     $                                 $                                 $
           $                     $                                 $                                 $

* Attach copy of Applicant’s loss exhibit showing breakdown of losses by amount and nature of loss.
* Attach copy of Insuring Terms of Present Policy (if available).

MERCHANDISE TO BE INSURED*

Full description of merchandise to be insured:

* Attach sales brochures, catalogues, pictures, etc.

PACKING*


APPLICATION – Open Ocean Cargo Policy
CE 12-03-01 (Rev. 1-81)                                                                                          Page 1 of 4
   Steel drums
   Fibre Drums:        Solid wooden cases          Open wooden crates         Export cartons
   Export bags
Are shipments containerized?             Yes        No
Percentage moving in containers door to door:                    %
   Other - Describe fully indicating materials, ply and strength of paper bags and cartons, use of skids, shrink-wrap, etc.:



* Attach packing specifications for all types of packing.

VOYAGES TO BE INSURED
Give Dollar Amount shipped to or from the following areas by means of shipment:

                                                                                                                     Parcel Post
To     From                              Areas                                   Steamer         Air Freight        (Incl. via air)

                  United Kingdom, Europe (Hamburg to Gibraltar)                  $                 $                   $
                  Scandinavia                                                    $                 $                   $
                  Europe, Mediterranean                                          $                 $                   $
                  Greece, Turkey and North Africa                                $                 $                   $
                  Africa (except as above) and Red Sea Area                      $                 $                   $
                  Near East                                                      $                 $                   $
                  Persian Gulf, India and Bangladesh                             $                 $                   $
                  Australia, New Zealand                                         $                 $                   $
                  Japan and Hong Kong                                            $                 $                   $
                  Far East (except as above)                                     $                 $                   $
                  West Indies and Hawaii                                         $                 $                   $
                  Mexico and Central America                                     $                 $                   $
                  North and East Coast South America                             $                 $                   $
                  West Coast South America                                       $                 $                   $

What is the average value per shipping package?            $                               Per conveyance?     $
What is the value per shipment by Air?         $                              Average weight per shipment by Air?               lbs
Is full value presently declared to the air carrier?           Yes       No


TERMS OF CONTRACT DESIRED
Insuring Conditions:            All Risks:     With Average Irrespective of Percentage          Free of Particular Average
                                Other - Explain desired coverage:
Desired Deductible:         $
Valuation:                      CIF +               %
                                Other – Explain or attach copy of present clauses:
Limits Of Insurance:        Steamer:                                 $



APPLICATION – Open Ocean Cargo Policy
CE 12-03-01 (Rev. 1-81)                                                                                                    Page 2 of 4
                           Aircraft:                               $
                           Parcel Post (Per package limit):        $
Are special policies (Certificates) required?        Yes      No         How many sets are used per month?
War Policy required?                                 Yes      No
Strikes, Riot and Civil Commotion?                   Yes      No


SPECIAL COVERAGES REQUIRED (Other than MEC and South American Endorsement)
   FOB/FAS                              Annual Dollar Volume:      $
   Contingency Insurance
   Import Duty Endorsement
   Banker’s Endorsement                 Bank Name:
   Automatic Warehouse Cover            Limits Required:      $
   Consolidated/Deconsolidation Cover
   Domestic Inland Transit
   Domestic Property and/or Processing
   Foreign Property and/or Processing and/or Transit
   Other – Specify:

Attach any other pertinent information which would affect underwriter’s consideration.


NOTICE
      The Applicant's submission of this Application does not obligate the Company to issue, or the Applicant to
      purchase, a policy. The Applicant will be advised if the Application for coverage is accepted. The Applicant hereby
      authorises the Company to make any inquiry in connection with this Application.

MATERIAL CHANGE
      If there is any material change in the answers to the questions in this Application before the policy inception date,
      the Applicant must immediately notify the Company in writing, and any outstanding quotation may be modified or
      withdrawn.

FALSE INFORMATION
      Any person who, knowingly and with the intent to defraud any insurance company or other person, files an
      application for insurance containing any false information, or conceals, for the purpose of misleading, information
      concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

DECLARATION AND SIGNATURE
      I have read the above Application. I declare that to the best of my knowledge and belief the statements and
      information in this Application and any attachments thereto are true, accurate and complete. This information is
      given to the Company for the specific purpose of obtaining insurance coverage. It is agreed that if any information
      given in this Application or in any attachments thereto is materially false, inaccurate or incomplete, the Company
      may deny coverage or cancel the policy.




                               Date                                    Authorized Signature




APPLICATION – Open Ocean Cargo Policy
CE 12-03-01 (Rev. 1-81)                                                                                            Page 3 of 4
                           Print Name                           Title




    Submitted by:

                     Agency:

                      Phone:    (       )   Fax:   (   )

                      E-mail:


PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE
AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED
TO BIND COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE
APPLICATION AND BINDS THE COVERAGE.




APPLICATION – Open Ocean Cargo Policy
CE 12-03-01 (Rev. 1-81)                                                          Page 4 of 4

				
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