Referral Details
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This merchandise can be considered for insurance but will need to be referred to InsureCargo in order to determine whether an insurance quotation can be offered.  Please provide the following information and a representative will be in contact with you as soon as possible.
* indicates a required field

Contact Information Section

Contact Name First

* M.I. Last *

Company Name *

Street Address 1


Street Address 2

Street Address 3





Zip/Postal Code




( ) - Ext. *

International Number


( ) -

International Fax




Shipment Information Section

Assured Information

Insured Legal Name


Loss, if any, payable to order of


Enter Commodity Details

Describe in detail the commodity to be shipped:

Condition of Commodity *

Enter Shipping Details

Number of Shipping Units (or weight if loose) Help?

* Units *
If not via Air, is it shipped in fully enclosed container(s) and/or truck(s)? YesNo*
If other packing, or not containerized, please describe, including dimensions of any bulk items:
Container Load FullLess than Full*

Professionally Packed


Refrigeration or Temperature Control Required?


Package Marks and Numbers Help?

Assured's Reference Number

Estimate Departure and Arrival Dates:
Estimated Date of Departure Month Day Year *
Estimated Date of Arrival Month Day Year *

Select the Primary Conveyance: Help?

Ocean Cargo (Vessel only, no barge)

      If Other, Enter Ocean Cargo Service

Air Cargo


Trucking/Rail Company


Name of the Vessel (if known)

Enter Departure and Arrival Location:

Coming From (city, state, country):


Going To (city, state, country):

Enter Valuation of Shipment:

Sum Insured (in USD) Help?

Format is xxxx.xx (Example $125,000.00). *

Miscellaneous Comments: 


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