Request

Company: *

First and Last Name: *

Email: *

Telephone: *

Fax:

Insurant (Name and adress of the insured according to the letter of credit): *

Name of the Cargo (in English): *

Insured Object (type of cargo, number of parcels, weight, type of package): *

Insured amount (enter the currency too): *

Total: *

Transported by: *

1. Train, number of the wagons: *

2. Truck, registration number, name of the carter: *

3. Sea, name of the ship, year of building and owner: *

4. Danube river, number of the barge and initials of the shipping company: *

5. Aeroplane, number of the flight: *

From (start location): *

To (end location): *

Through (intermediate location):

Insurance Start Date: *

The following risks to be coverd (accorting to the letter of credit or contract): *

I am familiar and I agree with the "General terms for cargo insurance in the time of transportation" of DZI from 1 May 1995: *
NO    YES

The insurance policy to be issued in originals and copies.