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Marine Cargo
Report of Shipment Request for Marine Insurance Coverage
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BSRM Ref #
Agency/Institution
*
Please select an Agency.
State or University Owned Property
Yes
No
Department
*
Please enter the Department.
Min 2 characters.
Letters, numbers, spaces . ' - only.
Contact
*
Please enter the Contact name.
Min 4 characters.
Letters, numbers, spaces . ' - only.
Project
*
Please enter the Project name.
Letters, numbers, spaces . ' - only.
Phone
*
Please enter a phone number.
Use 10 digits, dashes optional.
Declared Value
*
Please enter the declared value.
Min 2 characters.
Digits only - no decimal point or commas.
Shipment Destination
*
Please enter a Shipment Destination.
Letters, numbers, spaces , ( ) . ' - only.
Property Description
Letters, numbers, spaces , ( ) . ' - only.
1st Conveyance Carrier Information
Method of Transport
*
- Method -
Air
Ship
Truck
Rail
Other
Please select the 1st carrier's method of transport.
Role
*
- Select Role -
Vendor
Carrier
Broker
Forwarder
Please select the 1st carrier's role.
Name of Carrier
*
Please enter the 1st carrier's name.
Min 2 characters.
Letters, numbers, spaces . ' - only.
Phone
*
Please enter the 1st carrier's phone number.
Use 10 digits, dashes optional.
Earliest Departure Date
*
Please enter the 1st carrier's earliest departure date.
The earliest departure date cannot be in the past.
Latest Departure Date
*
Please enter the 1st carrier's latest departure date.
The latest departure date must be on or after the earliest.
1st Departure Point
*
Please enter the 1st departure point.
Min 2 characters.
Letters, numbers, spaces , ( ) . ' - only.
ADD ANOTHER CARRIER
Requesting Property Coverage at Destination?
*
- Select -
Yes
No
Please answer whether property coverage is requested at the destination.
Coverage Date From
*
Required when coverage at destination is requested.
The coverage start date cannot be in the past.
Coverage Date To
*
Required when coverage at destination is requested.
The coverage end date must be on or after the start date.
Location
*
Enter at least 2 characters.
Letters, numbers, spaces , ( ) . ' - only.
Who is your Risk Management Contact?
*
Please select a Risk Management Contact.
Who Else Should Receive a Copy of this Request?
Min 2 characters.
Separate addresses with ; - no commas.
Complete the captcha to submit the form.
Enter Verification Text
*
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