TNG CNG TY C PHN BAO MINH

BAO MINH
./0 9001: 2000 26 Tn Tht am, Qun 1, Tp.HCM - T: 84.8.38294180 - Fa : 84.8.3829418! " #ma$%: &a'm$nh.('m.)n " *+&,$t+: ---.&a'm$nh.('m.)n

1.23 345 C265 7890 H.49M H:;1 H<8

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 c !c " t#ng $ng%Please answer all the following questions by filling in or checking the appropriate boxes & !c th"ng tin co! d!u '() l b*!t bu"+c%Fields with (*) are compulsory.

,-. /ng 0i
New Policy

,#+. "ng ti t1c

enewal policy

2"! #n 3, c4!"ld Policy No566666666666666666666666

THNG TIN V NGI C BAO HIM/POLICY HOLDERS INFORMATION

67 6H 6K 6S 8n 9y : c: ;g#i #+c b <o hi<0=ch> ?; ,@A '()5
Full name of the policy holder in #$P%&$' '(&&(

6B

2C &D;E%FGGE5
%)!* N number

FI chJ '()5
$ddress

F8 nh5
+ome tel

6L

F8 di Mng5
,obile

6N

F8 c# Ou n5
"ffice tel

6P

2C Q R5
Fax No

FI chJ T0 il5
(-mail address

67U D > V"! thu! '()5

&ax code

677 ;ghW nghiX.Y ngnh nghW GE5

"ccupation. kind of business

67B ;gy Vinh%thnh lZ. &"ng ty5

)ate of birth!establishing company

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

67 6B 6^ 6L 6N 6P 8n hng h[ -c bo hi\0 '()5
,erchandise! #argo insured

2C h-. /ng th#ng 0]i%2C ,[ #n '()5

/ale #ontract!#ommercial %n0oice No

6H 6K 2C l-ng '()5
1uantity

;gy h-. /ng '()5

)ate of contract

8_nh cht b o b` '()5

Nature of packing

ah#ng th$c vZn chuy\n '()5

,ean of transport

8u bi\n
2essel

Dy b y
$ircaft

8n .h#ng tiXn vZn chuy\n '()5

Name of con0eyance

2 l n%%8u V"ng
*arge% i0er 2essel

XT ti
&ruck

;gy bhci hnh '()5

/ailing on or about

6S

dZn #n VC '()5
*ill of lading No

67U 8e '()5
From

677 Ffn '()5

&o

67B 2C l9n chuy\n ti '()5

Number of transhipment

67H ;#i chuy\n ti5

Place of transhipment

67^ 8rI gi bo hi\05

%nsured 0alue

YU C U BAO HIM/INSURANCE REQUEST

67 6B 6H 6K go]i h`nh bo hi\0 '()5
&ype of insurance

3, hng Rut bhhu

(xport

3, hng nhZ. bhhu

%mport

3, hng vZn chuy\n nMi I

%nland transit

;gi th1 hcng% FI chJ5

*eneficiary!$ddress

8ing VC tiWn bo hi\0 '()5

&otal %nsured amount

6^ ?6&6& 'A) 7SPB 3ulb oil m:i ro chifn tr nh

8j gi5
(x rate

FiWu biXn 3, ch_nh '()5

3nderlying conditions

?6&6& '3) 7SPB FiWu bhon d&;F c: 3D

*, %nland transit clauses

?6&6& '&) 7SPB Ghc5

"ther

krolTn Qood%0T t 6L FiWu biXn 3, .h1 '()5

m:i ro `nh c"ng

nt%4et

$dditional conditions

4ar risks

/trikes risks

8hifu h1t%/hortage Ghc

"thers

3\ vo%*reakage

;hip0 bhn%#ontamination

m:i ro Rf. do B 9u
'oading!unloading risks

6N 6P 6S

D$c bhu tre5

)eductible

3/i thng t]i '()5

#laim. if any. payable in!at

ah#ng th$c th nh ton .h_ bo hi\05

,ethod of payment

8iWn 0t
#ash

&huy\n bhon
*ank &ransfer

Ghc
"ther

qu c9u bhcY Rin ghi rr5

"ther requirement. please state

67U gi+ch V< b <o hi<0%%nsurance history5 ;fu > tng th 0 gi Y Rin cho bift tn c !c &ty 3,5
%f yes. please pro0ide the name of the %nsurers

F > tng th 0 gi 3,
+a0ing been co0ered

&h tng th 0 gi 3,
Not yet co0ered

2"! vu+ bhi!u n +i b <o hi<0 trong H n*0 gn y5

Number of claims in recent 5 years

8"<ng V"! tin bhi!u n +i b <o hi<0 trong H n*0 gn y5

&otal claims amount in recent 5 years

C!C CH"NG T# $NH %&M/ENCLOSED DOCUMENTS

,-. /ng th#ng 0]i
/ale contract

dZn ti #n%,F vZn chuy\n

*!' or carriage contract

,[ #n%ahifu Rut bho

%n0oice!)eli0ery receipt

ahifu [ng g[i

Packing list

8_n d1ng th
'etter of #redit ('!#)

& !c ch$ng te bhcY Rin li+t b5

"thers. please list

2 u bhi -c cung c!. c !c iu bho <n v %ho*+c Oui t*!c b <o hi<0 cu>ng nh #+c t vn 9y : vW Vn .hh0 bo hi\0 lin Ou nY chsng t"i%t"i Rin c 0 bft nh>ng iu b bh i trn y vW 0ti .h#ng diXn l ch_nh Rc v u!ng V+ th+tY bh"ng chT du bt c$ 0Mt th"ng tin no l0 nh hcng fn viXc nhZn bo hi\0 .
$fter being pro0ided as well as being ad0ised and fully understood the rele0ant insurance terms and conditions. %!4e warrant that all of the abo0e declaration is totally correct and true in all respects without any concealment that may effect the risk underwriting.

6666666666666666666666Y ng y!date66666666666666666666666666666 ;gi yu c9u bo hi\0%A..lic nt 'Gu tnY [ng du%2ign turT%Vt 0.)

PH N 'NH CHO (I )*/CNG TY MI GI+I/%HAI TH!C VIN

,t v tn G8d %]i lu %0"i gii '()5 Dw VC '()5 Dw VC '()5 ahng bh i thc VC5 FW Rut thi h]n th nh ton .h_5 yi h]nzz66ngy D$c 0ipn thng W Rut5 8h nh ton ng y 8hTo zzzz b{ zzzzz6Y ngyz6zthngz6zn*0zzz %,-. /,01 2.34/5. 67/M8. 9.:. 'GuY ghi rr ht tn) ,t v tn &n bM Ou <n ly! +i ly!%0"i gii '()5 &"ng ty thnh vin5 2C h-. /ng b o%nguyn txc5 Gh !ch h ng th 0 gi b <o hi<0 tr+c ti!. 'bh"ng chi ho h"ng)

| bifn .hn h/i c: Gh i thc vin%F]i lu%D"i gii5

;< H=> ?@49A

'B CD >,E4 B;U 9,. /F 1,GH49 /IJ4, PO)I;Y/A;IA

PH N 'NH CHO NGHIKP VL

Gh"ng ch. nhZn bo hi\0 &h. nhZn 3, thTo cc iWu biXn V u '/IB49 >,M4 1N>)5 P,O CPB ,.QRA )B5. >,O CPB ,.QR 76 ah_ bo hi\0 ch_nh B6 ah1 .h_ tu gi H6 ah1 .h_ chifn tr nhY `nh c"ng ^6 ah1 .h_ bhc T[NG C\NG T,]. ,54 /,-4, /B04 >,OA .^Y _.T4 CPB ,.QR C` aY49A 8TrriorV0 TRcluVion Fo n bft 0n nc 8h nh ton ng y ?2D TndorVT0Tnt &l VViQic tion Ghc 'ghi rr)5 zzzzz6Y ngyz6zthngz6zn*0zzz &n bM nghiX. v1 c: #n vI 'GuY ghi rr ht tn) yi h]n th nh ton trongzzzngy ?2a2 TndorVT0Tnt mT.l cT0Tnt qBG TRcluVion Fo n bft av? TS 6T >,O UVW P,O VAT P,O 9@R VAT P,3 XYZ3/ gu do te chCi5 FW Rut 3, thTo cc iWu biXn V u '/I34 >,M4 1N>)5

gwnh ]o #n vI .h duyXt 'GuY ghi rr ht tn)

* _.b4 1c- T`49 1849 /Z UTIB49 /IGH49 ,H> /I34 >,M4 1Md>WA

gwnh ]o 36}g;d%3A; F?~ ,;, 'GuY ghi rr ht tn)

zzzzz6Y ngyz6zthngz6zn*0zzz &huyn vin 36}g;d 'GuY ghi rr ht tn)