Please email: itic@thomasmiller.com Company Name Website Name and e-mail address of the person at your company to whom correspondence should be addressed SECTION 1 Activity for which insurance is required – Chartering broker Yes No Sale and purchase broker Yes No SECTION 2 Estimate of commission/management fee to be earned – (please indicate currency, e.g. US$) Total ALL YEARS forward commissions on all fixtures concluded: Over the next twelve months: Please list the three largest commissions which you require to be insured: US$ US$ US$ SECTION 3 Claims history – Have you ever suffered a loss of commission due to the total loss or constructive total loss of a ship Yes No
Please email: itic@thomasmiller.com Company Name Website Name and e-mail address of the person at your company to whom correspondence should be addressed SECTION 1 – Activity for which insurance is required Chartering broker Yes No Sale and purchase broker Yes No SECTION 2 – Estimate of commission/management fee to be earned (please indicate currency, e.g. US$) Total ALL YEARS forward commissions on all fixtures concluded: Over the next twelve months: Please list the three largest commissions which you require to be insured: US$ US$ US$ SECTION 3 – Claims history Have you ever suffered a loss of commission due to the total loss or constructive total loss of a ship Yes No
ITIC_-_F_-_Loss_of_Commision_Insurance_Proposal_Form.docx