TNG CNG TY C PHN BAO MINH

BAO MINH
ISO 9001: 2000

26 Tn Tht am, Qu n 1, Tp.HCM - T: 84.8.38294180 - Fax: 84.8.38294185 Email: baominh.com.vn Website: www.baominh.com.vn

GIY YU CU BAO HIM HNG HA

APPLICATION FORM FOR MARINE CARGO INSURANCE

Xin vui lng tr li tt c cc cu hi di y bng cch in hoc nh du vo cc

tng ng/Please answer all the following questions by filling in or checking the appropriate boxes
Cc thng tin co du (*) l bt bu c/Fields with (*) are compulsory.

Hp ng mi

Hp ng ti tc

New Policy

Renewal policy

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

THNG TIN V NGI C BAO HIM/POLICY HOLDERS INFORMATION

.1

Tn y ca Ngi c bo him-ch IN HOA (*):

.2

Full name of the policy holder in CAPITAL LETTER

.3

S CMND/KKD:
ID/BRN number

a ch (*):
Address

.5

T nh:

.6

Home tel

.9

T di ng:

.7

Mobile

a ch email:

T c quan:

.8

Office tel

S fax:
Fax No

.10 Ma s thu (*):

E-mail address

Tax code

.11 Ngh nghip, ngnh ngh KD:

.12 Ngy sinh/thnh lp Cng ty:

Occupation, kind of business

Date of birth/establishing company

THNG TIN HNG HA C BAO HIM/INSURED MERCHANDISE /CARGOS INFORMATION

.1

Tn hng hoa c bo him (*):

Merchandise/ Cargo insured

.2

S hp ng thng mi/S Hoa n (*):

.3

Sale Contract/Commercial Invoice No

.4
.6
.7
.8

Ngy hp ng (*):
Date of contract

Tnh cht bao b (*):

.5

S lng (*):

Nature of packing

Quantity

Phng thc vn chuyn (*):

Tu bin

My bay

Mean of transport

Vessel

Aircaft

Tn phng tin vn chuyn (*):

S lan//Tu sng

Xe ti

Name of conveyance

Barge/River Vessel

Truck

Ngy khi hnh (*):

.9

Sailing on or about

Vn n s (*):
Bill of lading No

.10 T (*):

.11 n (*):

From

To

.12 S ln chuyn ti (*):

.13 Ni chuyn ti:

Number of transhipment

Place of transhipment

.14 Tr gi bo him:
Insured value

YU CU BAO HIM/INSURANCE REQUEST

.1
.2

Loi hnh bo him (*):

BH hng xut khu

BH hng nhp khu

BH hng vn chuyn ni a

Type of insurance

Export

Import

Inland transit

Ngi th hng/ a ch:

Beneficiary/Address

.3

Tng s tin bo him (*):

.4

Total Insured amount

.5

iu kin BH chnh (*):

Underlying conditions

.6

T gi:
Ex rate

I.C.C (A) 1982

I.C.C (B) 1982

I.C.C (C) 1982

iu khon VCN ca BM

Khc:

BM Inland transit clauses

Other

Frozen food/meat

Bulk oil

iu kin BH ph (*):

Ri ro chin tranh

Ri ro nh cng

Additional conditions

War risks

Strikes risks

t/Wet

Thiu ht/Shortage

Ri ro xp d 2 u

B v/Breakage

Nhim bn/Contamination

Tin mt

Chuyn khon

Khc

Cash

Bank Transfer

Other

a tng tham gia BH

Cha tng tham gia BH

Having been covered

Not yet covered

Loading/unloading risks

Khc
Others

.7

Mc khu tr:
Deductible

.8

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

.9

Phng thc thanh ton

ph bo him:

Yu cu khc, xin ghi r:

Method of payment

Other requirement, please state

.10 Lch s bo him/Insurance history:

Nu a tng tham gia, xin cho bit tn cc Cty BH:
If yes, please provide the name of the Insurers

S v khiu ni bo him trong 3 nm gn y:

Tng s tin khiu ni bo him trong 3 nm gn y:

Number of claims in recent 3 years

Total claims amount in recent 3 years

CC CHNG T NH KM/ENCLOSED DOCUMENTS

Hp ng thng mi

Vn ti n/H vn chuyn

Hoa n/Phiu xut kho

Phiu ong goi

Sale contract

B/L or carriage contract

Invoice/Delivery receipt

Packing list

Tn dng th

Cc chng t khc, xin li t k:

Letter of Credit (L/C)

Others, please list

Sau khi c cung cp cc iu khon v/ho c qui tc bo him cng 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 l chnh xc v ng s th t, 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.

......................, ngy/date.............................
Ngi yu cu bo him/Applicant
(K tn, ong du/Signature/stamp)

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

H & tn KTV /i l /mi gii
(*):
H & tn Cn b qun l i l/mi gii (*):
Cng ty thnh vin:
S hp ng bao/nguyn tc:
Khch hng tham gia bo him trc tip
(khng chi hoa hng)

xut thi hn thanh ton ph:

Ma s (*):
Ma s (*):
Phng khai thc s:
Mc min thng xut:
Thanh ton ngay

Gia hn..ngy

Theo k

kin phn hi ca Khai thc vin/i l/Mi gii:

S Hp ng:

., ngy.thng.nm
Khai thc vin/i l/Mi gii
(K, ghi r h tn)

Do b phn BSU ghi t chng trnh POLISY/ASIA

PHN DNH CHO NGHIP V

Khng chp nhn bo him
Chp nhn BH theo cc iu kin sau (trong phn cp):
Ph bo him:
Loi ph bo him
T l ph (%)
Ph
1. Ph bo him chnh
2. Ph ph tu gi
3. Ph ph chin tranh, nh cng
4. Ph ph khc
TNG CNG
Thanh ton ngay
Thi hn thanh ton ph:

L do t chi:
xut BH theo cc iu kin sau (trn phn cp):
VAT

Ph gm VAT

Ph duy t

Gia hn thanh ton trongngy

ISM endorsement

ISPS endorsement

Y2K exclusion

Terriorsm exclusion

Classification

Replacement

oan kt P&I

oan kt mn nc

Khc (ghi r):

iu kin bo him b sung:

Lanh 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):

Lanh o B.QLNV/BAN IU HNH

(K, ghi r h tn)

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