Freight Brokerlogistics Liability Application

Freight BrokerLogistics Liability Application

1. GENERAL INFORMATION:

Company Name:
Address:
Contact: / Title:
Phone: / Fax: / E-mail:
Tax ID Number: / Years in Business: / FMCSA MC#:

1. COMMODITY INFORMATION

Principal Commodities Brokered

Does applicant arrange for shipments of the following? (if yes, what percentage of total shipments)

Autos/Boats Yes No % / Electronics Yes No % / Jewellery Yes No %
Refrigerated Yes No % / Artwork Yes No % / Hazmat Yes No %
Tobacco/Liquor Yes No % / Metals Yes No % / Machinery Yes No %
Pharmaceuticals Yes No % / Nursery Yes No % / Livestock Yes No %

On average, how many loads do you broker per month?

What percentage of shipments are LTL? %

Are you responsible for any packing, loading, or unloading? Yes No

Does applicant arrange loads on flatbeds? Yes No If Yes, how often?

Does applicant obtain certificates of insurance from carriers? Yes No

Is the limit of liability shown on the carriers’ certificate of insurance always equal to or greater than the shipment assigned to the carrier? Yes No

1. ACTIVITIES

Air Freight Forwarder Yes No % / NVOCC Yes No %
Domestic Forwarder Yes No % / Ocean Freight Forwarder Yes No %
Domestic Freight Broker Yes No % / Warehouse Operator Yes No %
Indirect Air Carrier (issue B/L) Yes No % / Customs Broker Yes No %
Other: %

1. FINANCIAL INFORMATION:

Actual for Prior 12 months / Estimated for next 12 months
Annual Gross
Freight Receipts / $ / $

1. INSURANCE/CLAIMS HISTORY

Yes / No
Are you currently insured for your professional liability exposure?
If yes, what is your current policy form: Occurrence Claims Made
*If claims made, please advise if prior acts is required: Yes No
If yes, please provide us with the following details:
Name of insurer:
Effective Date:
Premium:
Have any claims been made against the company or present
partners or directors in respect to Errors & Omissions, / Yes / No
Contingent Cargo, or Contingent Auto Liability?
(If yes, please attach full details)
Have you, at any time, been cancelled or refused similar insurance, / Yes / No
or had special terms imposed?
(If yes, please attach full details)

1. COVERAGES/LIMITS REQUESTED

Coverage Requested / Limit / Deductible
E&O / $ / $
Contingent Cargo / $ / $
Contingent Auto Liability / Third Party Liability / $ / $

Are you currently a member of CargoNet: Yes No

1. DECLARATION

The applicant declares that the information given in this proposal form are true to the best of his or her knowledge or belief and no facts which may influence the assessment of the risk have been misstated or suppressed.

If a contract of insurance is agreed, the applicant understands that the information given in this proposal will form part of the contract

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NameTitle

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SignatureDate

Compensation Disclosure to Clients

Integro is committed to providing superior service at the best value to our clients. When Integro makes any recommendation or offers any suggestion to a client pertaining to the placement or sale of insurance coverage, Integro does so in furtherance of the client’s interests.

In some instances, Integro is compensated by insurance companies or other third parties with whom Integro does business. That compensation may vary based on a number of factors, including the insurance contract and the insurer that the client ultimately selects, the volume of business that Integro provides to an insurer, and/or the overall book of business that Integro has with an insurer.

Integro welcomes discussion of its sources and forms of compensation. A client may obtain specific information about how Integro is compensated in connection with a particular placement or sale, or in connection with any alternative quotes presented by Integro to the client, simply by requesting such information from Integro.

In addition, please be advised that in conformance with applicable law, Integro holds premium funds in premium trust accounts segregated from Integro’s corporate bank accounts, and may earn interest on those funds until such time as they must be remitted. If you have any questions about the compensation that Integro may receive from work on your behalf, please do not hesitate to ask.

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