Mission name :

Type :    GPS position (lat/long) :

Localisation (Adresse) :

Appliquant (insured,forwarding,agent,broker,insurer,handler,shipping agent,other) :

Date of request :

Insured     :

Broker   :

Insurer :

Endorsement number :

Reference number of policy / Certificate of insurance :

        SEND TO :         Support sending required :

  Average Report 
        SEND TO :         Support sending required :

  Bills Fees & Expenses 
        SEND TO :         Support sending required :

Specific instructions (optional):


In order to comply with our internal guide line regarding contractual relationship our Company should be provided with a quotation for your services.

Accordingly we ask you to send us a quotation of estimated fees your firm will charge to carry on said instructions.

Such quotation will be considered has an indication and each and every extra works
terms or expenses in relation with such instruction will have to be communicated to the signatory of present message for information and/or specific agreement to be obtained.

Legal mentions

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