The application on insurance of cargoes

1. A subject of insurance (the nomenclature of a cargo) _________________

 Sort of packing:  _________________________________________________

2. Cost of a cargo: ________________________________________________

(_______________________________________________________________)

3. A route of transportation: ________________________________________

4. A way of transportation: autotransportation

5. The name of the forwarding organization: "Ulex" Ltd.
(the contract - application: № __ from __________)

6. Presence and the order of support of a cargo: the driver - forwarding agent

7. Documents for support of the goods:  _______________________________

8. Date of shipment ________________________________________________

9. Prospective time of a presence of a cargo in a way: ___________________

10. Desirable volume of a covering (under the discretion of the Insurant): with the responsibility for all risks: full volume of a covering

11. The unconditional franchise – 0,5 %.

12. The addressee of benefit: __________________________________________________________________
(the name of the legal person or a surname, a name, a patronymic of the physical person, the address of registration)

Seal ___________________