ONLINE CONTINGENT CARGO APPLICATION NOTE: CONTINGENT CARGO INSURANCE IS SECONDARY TO THE MOTOR CARRIERS CARGO POLICY
About Your Brokerage
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Applicant:
ICC Brokerage MC #:
Are You A Freight Forwarder?	Select One No Yes     If yes, provide FF number
Contact Name:
Mailing Address:
Telephone:
Fax:
Email Address:
Proposed Effective Date:
How Many Years in Business:
Have you ever had Contingent Cargo Insurance?	Select One No Yes
If so, with whom?
In the past 3 years, have you been named in any lawsuit?	Select One No Yes
If lawsuit, please explain:
In the past 3 years, have any claims been paid on your behalf?	Select One No Yes
If claims paid on your behalf, please explain:
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