Policy No. |
Transaction date |
Start Date |
Ref. Code (Agent / Broker) |
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|
|
|
|
FullName |
|
Contact Name (If different from above) |
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|
Email |
|
Tel. 1 (23480312345678) |
Branch |
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|
|
Address |
|
Occupation |
TIN Verify tin |
|
|
|
State |
LGA |
Identification |
Number |
|
|
|
|
|
Certificate (Serial) No |
|
Type of Cover |
Mode of Conveyance |
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|
|
|
Origin |
Destination |
Arival Date |
Nature of Cargo |
|
|
|
|
Proforma Invoice No. |
Issuer of P.I. |
Proforma Invoice Date |
Client Type |
|
|
|
|
Proforma Invoice Value |
Loading (%) |
Proforma Currency/Rate |
Packing Type |
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|
|
|
|
Conveyance |
|
Interest insured |
|
|
|
Marks & No. |
|
Conditions (Clause) |
|
|
|
Exclusion |
|
Loss Payee |
|
|
|
Excess |
|
Valuation Basis % Cost & freight Value / MPL (%) |
|
|
|
|
Sum Insured |
Premium Rate% |
Gross Premium |
Curr. Rate |
|
|
|
|
Marine Policy Type |
Coinsurance |
|
|