Tp

GIY YU CU BAO HIM HNG HAAPPLICATION FORM FOR MARINE CARGO INSURANCEXin vui lng tr li tt c cc cu hi di y bng cch in hoc nh du vo cac FORMCHECKBOX tng ng/Please answer all the following questions by filling in or checking the appropriate boxesCac thng tin co du (*) la bt buc/Fields with (*) are compulsory. FORMCHECKBOX

Hp ng mi FORMCHECKBOX Hp ng ti tc

New Policy Renewal policy

S n BH c/Old Policy No:.......................

THNG TIN V NGI C BAO HIM/POLICY HOLDERS INFORMATION1. Tn y ca Ngi c bao him-ch IN HOA (*):

Full name of the policy holder in CAPITAL LETTER2. S CMND/KKD:ID/BRN number

3. a ch (*): Address4.

5. T nh:Home tel6. T di ng:Mobile7. T c quan: Office tel8. S fax: Fax No

9. a ch email: E-mail address10. Ma s thu (*):Tax code

11. Ngh nghip, ngnh ngh KD:Occupation, kind of business12. Ngy sinh/thnh lp Cng ty:Date of birth/establishing company

THNG TIN HNG HA C BO HIM/INSURED MERCHANDISE /CARGOS INFORMATION13. Tn hng ha c bo him (*): Merchandise/ Cargo insured

14. S hp ng thng mi/S Ha n (*): Sale Contract/Commercial Invoice No15. Ngy hp ng (*):Date of contract

16. Tnh cht bao b (*): Nature of packing 17. S lng (*): Quantity

18. Phng thc vn chuyn (*):

Mean of transport

FORMCHECKBOX

Tu bin Vessel

FORMCHECKBOX

My bay

Aircaft

19. Tn phng tin vn chuyn (*):Name of conveyance FORMCHECKBOX

S lan//Tu sng

Barge/River Vessel FORMCHECKBOX

Xe ti

Truck

20. Ngy khi hnh (*):Sailing on or about21. Vn n s (*):

Bill of lading No

22. T (*):

From23. n (*):

To

24. S ln chuyn ti (*):

Number of transhipment25. Ni chuyn ti:

Place of transhipment

26. Tr gi bo him:

Insured value

YU CU BAO HIM/INSURANCE REQUEST27. Loi hnh bo him (*):

Type of insurance FORMCHECKBOX

BH hng xut khu

Export FORMCHECKBOX

BH hng nhp khuImport FORMCHECKBOX

BH hng vn chuyn ni aInland transit

28. Ngi th hng/ a ch:

Beneficiary/Address

29. Tng s tin bo him (*):Total Insured amount30. T gi:

Ex rate

31. iu kin BH chnh (*):Underlying conditions FORMCHECKBOX

I.C.C (A) 1982 FORMCHECKBOX

I.C.C (B) 1982 FORMCHECKBOX

I.C.C (C) 1982

FORMCHECKBOX

Frozen food/meat FORMCHECKBOX

Bulk oil FORMCHECKBOX

iu khon VCN ca BMBM Inland transit clauses FORMCHECKBOX

Khc:

Other

32. iu kin BH ph (*):Additional conditions FORMCHECKBOX

Ri ro chin tranhWar risks FORMCHECKBOX

Ri ro nh cngStrikes risks FORMCHECKBOX

t/Wet

FORMCHECKBOX

Thiu ht/Shortage FORMCHECKBOX

B v/Breakage FORMCHECKBOX

Nhim bn/Contamination FORMCHECKBOX

Ri ro xp d 2 u

Loading/unloading risks

FORMCHECKBOX

KhcOthers

33. Mc khu tr:

Deductible

34. Bi thng ti (*):Claim, if any, payable in/at

35. Phng thc thanh ton ph bo him:

Method of payment FORMCHECKBOX

Tin mt

Cash FORMCHECKBOX

Chuyn khon

Bank Transfer FORMCHECKBOX

KhcOther

FORMCHECKBOX

Yu cu khc, xin ghi r:Other requirement, please state

36. Lich s bao him/Insurance history: FORMCHECKBOX

a tng tham gia BH Having been covered FORMCHECKBOX

Cha tng tham gia BHNot yet covered

Nu a tng tham gia, xin cho bit tn cac Cty BH:

If yes, please provide the name of the Insurers

S vu khiu nai bao him trong 3 nm gn y:Number of claims in recent 3 yearsTng s tin khiu nai bao him trong 3 nm gn y:Total claims amount in recent 3 years

CC CHNG T NH KM/ENCLOSED DOCUMENTS

FORMCHECKBOX

Hp ng thng miSale contract FORMCHECKBOX

Vn ti n/H vn chuynB/L or carriage contract FORMCHECKBOX

Ha n/Phiu xut khoInvoice/Delivery receipt FORMCHECKBOX

Phiu ng giPacking list

FORMCHECKBOX

Tn dng th Letter of Credit (L/C) FORMCHECKBOX

Cac chng t khc, xin lit k:Others, please list

Sau khi c cung cp cac iu khoan va/hoc qui tc bao him cung nh c t vn y v sn phm bo him lin quan, chng ti/ti xin cam kt nhng iu k khai trn y v mi phng din la chnh xc v ung s tht, khng che du bt c mt thng tin no lm nh hng n vic nhn bo him.After being provided as well as being advised and fully understood the relevant insurance terms and conditions, I/We warrant that all of the above declaration is totally correct and true in all respects without any concealment that may effect the risk underwriting......................., ngay/date.............................

Ngi yu cu bo him/Applicant(K tn, ng du/Signature/stamp)

PHN DNH CHO I L/CNG TY MI GII/KHAI THC VIN

H & tn KTV FORMCHECKBOX /i l FORMCHECKBOX /mi gii FORMCHECKBOX (*):M s (*):

H & tn Cn b quan ly ai ly/mi gii (*):M s (*):

Cng ty thnh vin:Phng khai thc s:

S hp ng bao/nguyn tc:Mc min thng xut:

FORMCHECKBOX Khach hang tham gia bao him trc tip (khng chi hoa hng) xut thi hn thanh ton ph: FORMCHECKBOX

Thanh ton ngay

FORMCHECKBOX

Gia hn..ngy FORMCHECKBOX

Theo k

kin phn hi ca Khai thc vin/i l/Mi gii: ., ngy.thng.nm

Khai thc vin/i l/Mi gii

(K, ghi r h tn)

S Hp ng:Do b phn BSU ghi t chng trnh POLISY/ASIA

PHN DNH CHO NGHIP V

FORMCHECKBOX

Khng chp nhn bo himL do t chi:

FORMCHECKBOX

Chp nhn BH theo cc iu kin sau (trong phn cp): FORMCHECKBOX

xut BH theo cc iu kin sau (trn phn cp):

Ph bo him:

Loi ph bo himT l ph (%)Ph VAT Ph gm VATPh duyt

1. Ph bo him chnh

2. Ph ph tu gi

3. Ph ph chin tranh, nh cng

4. Ph ph khc

TNG CNG

Thi hn thanh ton ph: FORMCHECKBOX

Thanh ton ngay FORMCHECKBOX

Gia hn thanh ton trongngy

iu kin bo him b sung: FORMCHECKBOX

ISM endorsement FORMCHECKBOX

ISPS endorsement FORMCHECKBOX

Y2K exclusion

FORMCHECKBOX

Terriorsm exclusion FORMCHECKBOX

Classification FORMCHECKBOX

Replacement FORMCHECKBOX

oan kt P&I

FORMCHECKBOX

oan kt mn nc FORMCHECKBOX

Khc (ghi r):

Lnh o n v ph duyt

(K, ghi r h tn)., ngy.thng.nm

Cn b nghip v ca n v (K, ghi r h tn)

kin ca Tng cng ty (Trong trng hp trn phn cp):

Lnh o B.QLNV/BAN IU HNH

(K, ghi r h tn)., ngy.thng.nm

Chuyn vin B.QLNV (K, ghi r h tn)