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Shipper

Full Name

Address

Do we need to pickup the vehicle at this address? Yes No

Telephone

Fax

Email

Passport # or Social Security #

Billing Party

Full Name

Address

Telephone

Email

Ultimate Consignee

Full Name

Address

Telephone

Email

Commodity

Insurance Information

Marine Insurance Requested Yes No

Premium 1.85 % of Declared Value 2.00 % of Declared Value 2.50 % of Declared Value

Amount Insured