Logistics Liability Insurance

Your Name

Your Address

State

Post Code

Telephone

Email

Website

Please advise details of any related companies to be named in this insurance policy
List the Name, Services Offerred and Relationship (Eg. Subsidiary, Joint Venture)

Services Provided

Please advise the full title of any statute or other legislation governing operations at the nominated Insured Locations. Please provide copies of all relevant documentation establishing ISPS Code (or other security regulation) compliance at the nominated Insured Locations.

MAJOR FACILITIES:

DESCRIPTION

NUMBER

OPERATED/OWNED

OPERATED/LEASED

LEASED TO OTHERS

Distribution Centre

Container Freight Station

Warehouse - Dry

Warehouse - Refrigerated

Inland Container Depot

Intermodal Rail Depot

Other

INSURED SERVICES:

DESCRIPTION

% GROSS REVENUE

YES/NO

SUBCONTRACT YES/NO

NAME OF SUBCONTRACTOR

Ocean freight forwarding

Air Freight Forwarding

Storage

In-Transit Storage

Long Distance Haulage

Local Delivery and Collection

Freight Forwarding Agent Only

Product Preparation and Configuration

Customs Broking

Packing/Consolidation Service

Other

Other: Describe the nature of the service provided

Subcontractors

Please list the type and number of subcontractors you use in your operation

Drivers - Short Haul—Please choose an option—YesNo

If Yes, Number:

Drivers - Long Haul—Please choose an option—YesNo

If Yes, Number:

Loader/Unloader—Please choose an option—YesNo

If Yes, Number:

Storeman/Packer—Please choose an option—YesNo

If Yes, Number:

Have you agreed with any of your subcontractors to:

Limit or exclude their liability?—Please choose an option—Yes - In WholeYes - In PartNo

Limit or exclude your liability? —Please choose an option—Yes - In WholeYes - In PartNo

Be indemnified by them in respect of your liability?—Please choose an option—Yes - In WholeYes - In PartNo

Indemnify them in respect of their liability?—Please choose an option—Yes - In WholeYes - In PartNo

If you answered Yes to any of the above questions, please provide details:

Financial Details

Please advise annual gross revenue

Actual gross revenue – previous year:

Estimated gross revenue – this year:

Please estimate the percentage of gross revenue

Paid to subcontractors (local carriers, consolidators, de-consolidators etc.)

Attributable to the following methods of handling:

Break-Bulk

Containerised

Palletised

Attributable to carriage within the following regions:

Australia

New Zealand

South Pacific

Europe

Asia

Americas

Represented by the following types of cargo:

Refrigerated Cargo

Personal Effects

Electronics

Dangerous Cargoes

Valuable Cargoes

Project Cargoes

Employee Information

Number of Employees

Managerial

Administrative

Operational

Cargo Handling

Other

Total employees

Other: Describe the area the employee works in

Are the cargo handling employees:—Please choose an option—Employed directly by you?Employed by a subcontractor?Employed by a tenant?Hired from the port labour pool?

Customer Contract Information

Please indicate the form of contract with your Customers:—Please choose an option—Standard terms and conditions of serviceIndividual customer arrangements *Standard lease agreementsNoneOther

If Other: Please describe the details

* Where you have entered into individual customer arrangements, please list the names of the major contracts (Please provide copies of these individual customer contracts):

Please indicate the standard of liability under these Customer contracts.—Please choose an option—Limited liability in negligenceNo liabilityUnlimited liability in negligenceOther

If Other: Please specify

Storage and/or Distribution Facilities

Please provide details of your storage and/or distribution facilities

ADDRESS

FLOOR SPACE (Sq m)

TYPES OF GOODS STORED

AVERAGE VALUE OF GOODS STORED AT ANY ONE TIME

Current Insurance

Please provide the following information about your current insurance policy:

Name of Insurer

Renewal Date

Limit of Liability

Deductable(s)

Premium

Claims History

Please provide details of the claims history for the company, whether below the deductible or not, for the past five (5) years including type of claim (whether settled, rejected or pending), the value of the claim (contracted and paid)

Declaration

I/We authorise Midas Insurance Brokers to collect or disclose any personal information relating to this insurance to/from any other Insurers or insurance reference service.

I/We declare that I/we have read and understood the duty of disclosure, non disclosure and policy conditions contained herein and confirm that no information has been withheld which could affect the acceptance of this application.

Name of Proposer

Date

No insurance cover is provided until this Proposal Form is accepted and details of cover are confirmed in writing by Midas Insurance Brokers.