Hauliers Liability Insurance Proposal Form
 
Please select the country/city where the form is to be submitted
A. General Information  
Insured Name (in Block Capitals) :
(as will appear on the Policy)
Address :
Telephone No :
Fax No :
E-mail :
Name of the Company to be Insured :
Address of the Company to be Insured :
Number of Years in Business :
Other Offices :
B Territorial Limits:
Countries for which cover is required:
Press Ctrl to Select more than one country
C. Conditions of carriage
Please state under which conditions of carriage you operate for:
a. Domestic Operations
b Other Middle East Operations
c. European Operations
Note: Copies of all standard license of destinations for which cover is required must accompany this application.
D. Gross haulage Charges
Please state your Annual Gross Haulage Charges (the total turnover for transport operations and warehousing) including Sea Freight excluding customs duties and other taxes paid on behalf of any principal.
Estimated charges – Current year
Estimate charges – next year
Estimated charges – last year
Please provide a breakdown of (a) above to estimated percentage,
Operations Domestic International
(i) Using own vehicles
(ii) Using sub contractors vehicles
(iii) Acting as a warehouse-keeper
E. Vehicle Information
Please give details of number of vehicles & average age of the fleet:
F. Limits of liability
Please state the maximum limits of liability required.
a. Any One vehicle / Trailer 
b. Any One Location / Loss 
G Goods Carried
Please give details of principal goods carried and/or stored:
If any of the following goods are carried / stored, please state the estimated percentage of turnover applicable and the annual/maximum values carried.
No: TYPES OF GOODS %TURNOVER LIMIT
1 Tobacco, Cigars, Cigarettes
2 Spirits
3 High Value Cargo (Jewellery, Works of Art, Bullion)
4 Project Cargo
5 Refrigerated or Temperature controlled cargo
6 Livestock / Bloodstock
7 Goods of Dangerous Nature
8 Bulk Cargo (Cement, Grain, etc.)
9 Tank Container Cargo.
10 Others
H. Claims History
Please State the number and total amounts of all paid and pending claims made against you (Whether you have been insured or not) during the past 5 years.
YEAR CLAIMS PAID  CLAIMS PENDING
I. Existing Insurance
   Please Provide:
1 Name and Address of Current Insurer
2 Amount of Excess applying to present insurance
3 Expiry Date of present insurance.
J. Other Information
Please state any other information, which may be considered relevant to this application:

 

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