Freight Insurance Order Form

Freight
Insurance
Center

Freight Insurance Order Form
For Immediate coverage/policy issued for a Single Shipment or Move.

For All Shipment types/Moves, Any Value, Domestic & International by Land, Air or Ocean.

Enter your shipment details below to purchase freight insurance
coverage. Your policy / certificate of insurance will
be issued immediately and sent to you via email.

If you have NOT received a Quote from us, view the Online Rates

If you have already received a Quote from us, you may enter it below. Your Quote is a custom preferred rate for your particular shipment, enter it below to receive your special price.

                                                            Freight Insurance Order Form


        Individual or Company Name:    Contact Person:

        Address:     City:    State/Prov:

Country: Zip/Postal Code:

Phone: E-mail Address:

Please make sure your Email address is correct, no typos.
This is where your freight Insurance Certificate and Payment receipt will be sent.

   Insured Value / Insurance Coverage Amount: $ in US Dollars

   Insured value is the total actual value of your goods being shipped.
    For Brand New goods, it's the Invoice price + shipping cost (if you wish to include, optional).
    For Used goods, it's the estimated / declared actual Replacement cost + shipping / moving
    costs (if you wish to include, optional).

Shipment Date:

Name of Insured: (Person the loss is payable to)

If it's an individual, please enter the first and last name.

Shipment Reference # (BOL #, Pro# , Moving #, Order #, Invoice#, etc):

   1st Package Type
    Number of boxes, pallets or crates... etc: #

    2nd Package Type:
    Number of boxes, pallets or crates...etc: #   (Optional)

Help Example: If you have 20 boxes and 2 crates, under 1st package type you would enter 20 and select "boxes" from the drop down menu and then under Second package type you would enter 2 and then select crates from the menu. If your shipment consists of only 1 package type (for example all boxes) then you can leave the Second package type blank and just fill in the first package type.

Packaging:

Description of goods being insured:

Used Goods Used & Fully Reconditioned goods New goods

ITEMS / GOODS CATEGORY:

Click here to View the Category Definitions & Determine the Correct Category of Your Goods
Please use the chart in the link above to ensure you select the correct category to be properly covered.

Insurance Coverage Type:

Click here to View and Compare Coverage Types

Name of Shipping Carrier or Moving Company:

    (The actual carrier who is transporting your goods. If you are using a freight broker
    or moving broker and do not know which carrier, just put the broker name.)

   Mode of Transport:

Shipping FROM

City: State: Country:

Shipping TO

City: State: Country:

Did you obtain a Quote for this freight insurance policy by submitting the Quote form,
by email or by speaking direct with a P.A.F representative?

If Yes, please enter your Quote below:

Quoted Price: $ Quote #:

Deductible Quoted:

If the above is a Valid Quote, you will be charged this amount.

Click here to view the Online Rates
and How to Calculate Your Policy Charge
if you have NOT received a Quote from Us.

Payment: We do not process credit card transactions through the Internet. We have our own secure credit card terminals, in our offices, for safe processing. You may safely enter your credit card information below, because it is protected by our Secure SSL Encrypted Website Server and cannot be intercepted or seen by anyone. Your information will only be seen by us, on our Secure SSL Server, and then the transaction will be processed here in our office, instead of a 3rd party processing company. However, If you feel more comfortable, you may also call us to give your payment info. over the phone.

Credit Card: #:--- 3 or 4 Digit Security Code:

Your Credit Card has a 3 digit Security Code found on the back of your card, listed after your credit card number in the signature area. We request that you enter this code as an added security measure. The security code is circled in the example picture on the right.

Exp Date:

I authorize P.A.F to charge my credit card for the cost of this Cargo Insurance Policy, according to the
Quote I received from a P.A.F representative, plus a credit card merchant fee of 4% of the quoted price with
a $5 minimum, or if NO quote received then the online rates and category definitions listed on the
"Online Freight Insurance Rates" page on this website, plus the 4% card fee. I agree not to charge-back any purchases for certificates/policies of insurance that have already been issued. YES

Please sign that you agree to the rate/policy charge and terms of the insurance coverage selected
by typing your name:

Credit Card Billing Address:
Please check this box if the billing address for the credit card is the same as above:
If it is the same, you can leave the fields below blank. If the billing address for the credit card
is different then the address at the top of the form, then please fill in the fields below.

Address: City: State:

Country: Zipcode/Postal Code:

Exact Name on Credit Card:

How did you hear about us:

If Other Company or Search Engine, Please enter Name:

Who from our company did you speak with?:

(who assisted you via phone or email? If you were able to obtain all information
and answers from our website, please select "No one/website" above. If you spoke with one of our executives via phone or email, please select their name above.) If you are a repeat client/regular customer, then please select "Repeat client".

Letter of Credit Wording if Required by bank or other (Optional):

Comments: (Optional)

If you have any other details you wish to provide you may do so in the comments box above. If you were given a quote over the phone, you may enter it here along with the name of the representative who provided the quote.

SSL stands for Secure Sockets Layer and is the Internet's leading Security Protocol, designed to prevent the interception of private or sensitive information sent over a computer network or the Internet. (I.e.: protection against hackers). SSL enables encrypted, authenticated communications across the internet ensuring that all online communications are secure and cannot be intercepted while in transit. Please be assured that any information you submit on our site will be protected by our SSL secured Web Server.

Terms and Conditions of Insurance CoveragePlease note that we cannot bind/place coverage over the phone, all insurance purchases must be ordered through this application order form which can be submitted here via this website or by fax and these terms of coverage stated herein must be read and agreed to before we can issue your policy of coverage. By submitting our application form you are agreeing that you have read and understand the terms and conditions of coverage at: http://www.pafins.com/freightinsurancestandardpolicyterms.htm . You may view these terms in another window by clicking the "Terms and Conditions of Insurance Coverage" link beneath this box. Please call us with any questions you have and we'll be happy to explain. When purchasing insurance, you certify that all information provided is accurate and truthful. The submission of a false, fictitious, or fraudulent statement may result in imprisonment of up to 5 years and a fine of up to $10,000 (18 USC 1001). In addition, a civil penalty of up to $5,000 and an assessment of twice the amount falsely claimed may be imposed (31 USC 3802). Warning: any fraudulent claims will make the shipper and/or consignee liable for any prosecution for mail fraud under federal crime code. In order to protect your interest, you, as the cargo owner authorize Pacific Atlantic Freight (PAF) to act as your agent for arranging or assisting with the carriage of your cargo/personal goods in order to procure insurance on your behalf. This will also allow and authorize us to procure the insurance on your behalf and perform any related document preparation for transport and assist with any claims preparation and or activity. Please make sure you wish to proceed with the purchase of insurance, as there are no refunds or cancellations after the insurance certificate/policy has been issued, unless you need to make a change to the information detailed on the certificate, in which we can cancel the first certificate and issue a new certificate with the correct information. In the case of cancelled shipments, you may apply the policy charge as credit towards coverage/policies for future shipments. This rule helps the insurer to prevent fraudulent orders, i.e.: canceling insurance after the shipment has been delivered safely. In special circumstances, exceptions can be made.

I have Read and Agree to the Terms and Conditions of Insurance Coverage Yes

By submitting this application order form you agree that you have:
1) Read, understand and agree to the terms and conditions of coverage in the link above.
2) Viewed the category definitions table, linked above, to select the correct category of your items.
3) If you did not obtain a quote directly from P.A.F, then you agree that you have viewed the online rates chart (linked at the top of this form) and have calculated your policy charge. In absence of a valid quote, this is the amount that will be charged to your credit card today for the purchase of this insurance coverage/policy.


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