COÂNG TY COÅ PHAÀN BAÛO HIEÅM BÖU ÑIEÄN (PTI)-CHI NHAÙNH TP.

HCM
VNPT POSTS AND TELECOMMUNICATIONS J.S INSURANCE CO. - HOCHIMINH BRANCH
Insurance 6-8-10 Phan Xích Long – PN ÑT: 08 - 5174802 Fax: 08 - 5174809

GIAÁY YEÂU CAÀU BAÛO HIEÅM HAØNG HOÙA

INSURANCE REQUEST ON CARGO

Teân vaø ñòa chæ cuûa ngöôøi ñöôïc baûo hieåm: ....................................................................................................
Name and address of the Insured: ............................................................................................................................
Ñieän thoaïi/ Fax (Tel/ Fax No.): Fax: ...................................................................................................................
Taøi khoaûn taïi ngaân haøng soá (Banking account No.): ........................................................................................
Maõ soá thueá (VAT Code): ....................................................................................................................................
Yeâu caàu Chi nhaùnh Coâng ty coå phaàn baûo hieåm Böu ñieän taïi TP.HCM baûo hieåm haøng hoùa theo keâ khai
vaø nhöõng ñieàu kieän ghi döôùi ñaây (Requests Posts & Telecommunications Joint - Stock Insurance Company to
insure the following goods subject to the conditions and / or clauses as specified hereinafter ):
Vaän Soá kieän Teân haøng hoùa Soá tieàn baûo hieåm
taûi ñôn Number of Troïng löôïng Kyù maõ hieäu ñöôïc baûo hieåm (giaù trò baûo hieåm)
soá Pieces/packages Weight Marks & numbers Goods insured Amount insured
B/L No (and so valued)

- Soá L/C (L/C No.):...................................................................................................................................................

- Hôïp ñoàng mua baùn soá - Contract No.: ..............................................................................................................
- Tính chaát bao bì - Nature of packing (ñoùng container, ñoùng boù, carton,..):......................................................
- Phöông thöùc xeáp haøng (döôùi haàm, treân boong, ñeå rôøi,…):........................................................................
- Phöông thöùc vaän chuyeån - Means of packing:.....................................................................................................
- Teân taøu vaän chuyeån - Name of vessel: .............................................................................................................
- Ngaøy khôûi haønh - Sailing on or about: .............................................................................................................
- Töø - From..............................Chuyeån taûi - Transhipment........................Ñeán - To..........................................
- Toång soá tieàn baûo hieåm - Total amount insured:...............................................................................................
- Tyû leä phí chaáp nhaän – Accepted rate : ……………………………………
- Ñieàu kieän baûo hieåm - Condition of insurance:..................................................................................................
- Thanh toaùn boài thöôøng taïi - Claims payable at: ................................................................................................

…………giôø, ngaøy – dated……………. on……………

200
NGÖÔØI ÑÖÔÏC BAÛO HIEÅM – INSURED