Automated Systems, Inc.

Insurance Form

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Bill To

Customer Number:
Company Name:
Address:
City:
State/Country:
Zip:
Telephone:
Fax:
Contact Name:
E-mail:

 

Loss Payable To

 

Company Name: 
     Address: 
City: 
 State/Country: 
 Zip: 
    Telephone: 
  Fax: 
 Contact Name: 
  E-mail: 

       

Shipper (From)

 

City:
State/Country:

 

Receiver (To)

 

City:
State/Country:

Type of Shipment: Click on the arrow.  Choose the proper method for this shipment.
Method of Shipment:

Loaded On Deck: If you are shipping, for example, a yacht or heavy equipment which will not fit under deck, click this window.  If not, leave this window blank.
Carrier:

Pro/Airbill/Carrier #:
Ship Date:   Date insurance begins
Declared Value ($ US):

Description of items

Shipped/Insured:

 

There is plenty of room in this window to enter the detailed information required by Letters of Credit or other contracts.

 

What you type here prints verbatim on the Certificate.

 

                       

 
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Last modified: November 25, 2003
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