Marine Underwriting Services S IA Tel.

: +1761 67 830 870

Reg. No. 40103608205 Fax: +135443734322
10452 Chicago city,Minnesota 55013

SINGLE SHIPMENT CARGO INSURANCE

APPLICATION FORM
Please note that it is a duty of the Assured to provide full and accurate information to Underwriters and their agents and failure to do
so may result in Underwriters’ right to reject a claim which relates to circumstances which should have been disclosed or which is
subject to misleading or inaccurate information.

1. ASSURED

COMPANY NAME
Mcewen Law Firm

REGISTRATION N O DATE OF INCORPORATION

199866645 20-11-2023

ADDRESS
5580 Blackshire Path Inver Groove Heights,MN 55076

CONTACT PERSON (NAME, SURNAME)

Mcewen Gregory

PHONE WEB PAGE E-MAIL

mcewengregory28@gmail.com30

2. YOUR INSURANCE BROKER

COMPANY NAME
Westfield insurance

REGISTRATION N O
23689000

ADDRESS
3601 W 76th St Ste 275,Minneapolis,MN 55435

CONTACT PERSON (NAME, SURNAME)

Margret Baker

PHONE E-MAIL

3. COMMODITY TO BE INSURED

PLEASE PROVIDE A BRIEF DESCRIPTION OF COMMODITY TO BE INURED

30 bars of quality refined gold ..tested and approved

IS THE COMMODITY(IES) (PLEASE CHECK ONE)

BRAND NEW RECONDITIONED SECOND-HAND

ARE GOODS PACKED BY (PLEASE CHECK ONE)

MANUFACTURER / OWNER (OTHER THAN
PRODUCER MANUFACTURER) OTHER
Mcewen Gregory

1/2 Single Shipment Cargo Insurance . A pplication Form www.underwriting.lv

4. INSURED VALUE / VALUATION

PLEASE INDICATE TOTAL SUM INSURED EUR USD

576

IS INSURED VALUE REPRESENTED AS

INVOICE VALUE 110% OF INVOICE VALUE OTHER

5. VOYAGE

PLEASE ADVISE THE TRANSPORT ROUTE AS FOLLOWS:

FROM (CITY, COUNTRY) VIA (CITY, COUNTRY) TO (CITY, COUNTRY)
United states Netherlands

6. MODE OF SHIPMENT
ARE GOODS SHIPPED BY (PLEASE CHECK ONE)
ROAD RAIL AIR SEA (CONTAINERIZED) SEA, BY MV OTHER (PLEASE DESCRIBE)

7. REQUIRED INSURANCE COVER

ARE YOU INTERESTED IN (PLEASE CHECK ONE)
ALL RISKS COVER NAMED PERILS COVER SPECIFIC COVER (PLEASE DESCRIBE)

APPLICATION FOR INSURANCE

APPLICATION SUBMITTED BY APPILICATION DATE

Gregory Mcewen 20-11-2023

2/2 Single Shipment Cargo Insurance . A pplication Form www.underwriting.lv