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	Application form for a Loss Prevention
Fields in bold must be filled in

Applicant’s data

Name of Company Type of Company select insurance company broker goods consignor goods consignee shipping agent carrier goods seller purchaser goods depositor end consignor other Name of the individual Via Phone Number Zip Code Fax Town E-mail Prov. VAT number Possible notes for invoice

Type of intervention

Urgent   Ordinary       Object of the survey Type of survey select verify stowage verify fastening verify packing other     Value of the goods involved     Type of transport (if applicable) select road/railway sea air intermodal     Identification of the transport means (number plate or data of the means, if applicable)

Site of intervention

Name of the Company or site Address Town Province Contact Mr/Ms Phone number

Support documentation

Enclosed to this form     Only annexes     Follows by fax  fax n° +39-02-95341937     Not currently available

Notes and/or special instructions   How may we contact you? Phone   e-mail

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