Application

CONTACT INFORMATION (* denotes required fields)

First Name:* Last Name:*
Title:
Company:*
Address:*
City:* State:*  Zip:* 
Phone:* Extension: 
Fax: Email: 
Website:

SHIPPING INFORMATION

Avg # of INSURED packages per day:* (packages greater than $100)
Avg value of INSURED packages:*
Maximum value per package:*
What kind of products do you ship?*

Carrier(s) used (check all that apply):*
     UPS®
     FedEx® Express
     FedEx® Ground
     DHL®
     U.S. Postal Service
     Other 

What kind of shipping manifest system do you have?*
     UPS® Worldship
     FedEx® Café
     FedEx® ShipManager Workstation
     FedEx® Online
     DHL® Easy Ship
     Clippership
     Harvey Software
     Starship
     Manual Book
     Other 

What date would you like to start on?*     

Note: Coverage will only become effective upon receipt of this application by
SHIP-INS and approval has been confirmed by SHIP-INS.