Inquiry Form
Please fill in the inquiry form, our consultant will be in touch shortly.
Client Profile
Name
*
Phone
*
Mobile
Email
*
Insured Profile
Name
*
Address
*
Phone
Mobile
Email
Shipment
Period Of Cover (dd-mm-yyyy)
*
To Duration
Coverage
*
-- select --
ICC A
ICC B
ICC C
Personal Effect
Inland Transit
Shipment Type
*
-- select --
Domestic
Export
Import
Inland Transit
Inter Island
Land Transit
Project Shipment
Re-Export
Trucking
XOL
Transportation Type
*
-- select --
Air
Land
Sea
From
*
To
*
Original Currency
*
-- select --
IDR
USD
EUR
SGD
Sum Insured
*
Conveyance
*
Interest Insured
*
Bill of Lading No.
Memorandum No.
Policy Document
Do you required hardcopy? An additional charge for policy cost shall be added on accordingly
No
Yes
Security Verification
Please fill in the number above in the verification code :
*
Submit
Disclaimer
The information contained in this application form is true, and the insured object is in the Indonesian territory. PT Howden Insurance Brokers Indonesia is not liable to any lawful obligations arising from any false information in this application form whatsoever.