Company Name:

Address:

City:

State:

Zip Code:

Title:

Contact name:

Phone:

Fax:

Email Address:

Packages Shipped Per Month:
  

Packages Insured Per Month:
  

Maximum Value Per Package:
$

Average Value Per Package:
$

Commodity Shipped (please be specific):
  

Do you ship internationally ?

Shipping Software:









Others:

Start Date: (would like coverage to begin on*)
    mm/dd/yyyy

*U-PIC does not guarantee that a policy will be issued or that this Start Date can be met.



(Choose all that apply.)




A 2 year Claim history required for coverage.

How many claims in last 2 yrs:
  

Total dollar value of claims in last 2 yrs:
$