FREIGHT FORWARDERS LIABILITY PROPOSAL FORM

1. NAME & ADDRESS OF APPLICANT:

Tel: Fax: Email: Website:

2. BACKGROUND INFORMATION: Please provide details of when company was established,offices, number of staff etc., etc.

3. WHAT TRADE ASSOCIATIONS IS YOUR COMPANY A MEMBER OF:

4. NAMES & QUALIFICATIONS/EXPERIENCE OF DIRECTORS & SENIORMANAGERS:

Name Qualifications Experience (Years) 1 2 3 4 5 6 7

Qatari Shareholding Company l Licensed by Qatar Central Bank l Capital QR 255,279,02 (paid in full) l C.R. 7095 T +974 44041111 l ktg@alkhaleej.com l www.alkhaleej.com l Toll Free 8005007

P.O. Box: 4555 Doha – Qatar l 76 Grand Hamad Avenue - Area 5 l Fax + 974 4443 0530

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5. EMPLOYEES:

Number of Directors, Senior Managers Number of Clerical Employees Number of Non-Clerical Employees Others (Please specify)

6. GROSS FREIGHT RECEIPTS (GFR): The information to be detailed shall include GrossRevenues plus payments to agents and subcontractors in respect of transport services but excluding customs duties, sales tax or similar fiscal charges paid on behalf of customers.

Income past 12 Months Income Current 12 Months Income Next 12 Months

What percentage of your annual income is derived from

Breakbulk % Approx. Tonnage Containerised % Approx. No. of TEUS Palletized % Approx. Tonnage

Please estimate the percentage of annual traffic to or within each of the following areas.

North America % Northern Europe % South America % Southern Europe % Central America % Russian Federation % Asia excl. China % Australasia % China / Hong Kong % Other, please specify %

What percentage of your annual income is represented by

Perishables % Refrigerated Cargoes Electronics % Project Cargoes Tank Containers % Dangerous Goods High Value Goods % Household Goods

Do you have any consignments of the following where value including duty exceeds USD50,000

Spirits / Alcohol Yes No Works of Art Yes No Cigarettes / Tobacco Yes No Bloodstock / Livestock Yes No Jewellery Yes No Gold/Silver/Platinum Yes No

Qatari Shareholding Company l Licensed by Qatar Central Bank l Capital QR 255,279,02 (paid in full) l C.R. 7095 T +974 44041111 l ktg@alkhaleej.com l www.alkhaleej.com l Toll Free 8005007

P.O. Box: 4555 Doha – Qatar l 76 Grand Hamad Avenue - Area 5 l Fax + 974 4443 0530

7. WAREHOUSING / OWNED VEHICLES: Please complete the following if you operate yourown vehicles, warehouse(s) or packing/consolidation facilities.

A) Warehouse Location(s) Services Provided Security at Warehouse

B) Your Vehicles Cargo Carried Delivery Status (KM)

8. SERVICES TO BE INSURED.

No. of Years Approx. % of Turnover Yes No Ocean Freight Forwarder/NVOC Yes No Customs Broker Yes No Local Carrier Yes No Air Freight Forwarder/Air Cargo Agent Yes No In-transit Warehousing Yes No Packaging/Consolidating Yes No Road Haulier Yes No Other (please specify below)

What C/P forms are used?

What C/P forms are used to sub-charter?

Do you use contracts of affreightment or other similar contracts Yes No Do you issue the B/L in a form that identifies you as the carrier Yes No If you have answered Yes to the above then please advise whether you issue: Through Transport B/L Yes No Combined Transport B/L Yes No

9. TRADING AREA: Please specify the countries you most frequently load / discharge cargo.

Qatari Shareholding Company l Licensed by Qatar Central Bank l Capital QR 255,279,02 (paid in full) l C.R. 7095 T +974 44041111 l ktg@alkhaleej.com l www.alkhaleej.com l Toll Free 8005007

P.O. Box: 4555 Doha – Qatar l 76 Grand Hamad Avenue - Area 5 l Fax + 974 4443 0530

10. TRANSHIPMENT / LIGHTENING: Please provide details of Transhipment/LighteningOperations.

11. CLAIMS HISTORY:

Year Paid O/S Total 2004 – 2005 2005 – 2006 2006 – 2007 2007 – 2008 2008 - 2009

2010

Please provide details of current insurance carrier.

Please provide details of individual claims on a separate sheet.

Please provide copies of last annual report and accounts, company brochure or literature together with any other information that could assist.

Signed Date

Company Position

Disclosure of Material Facts Every Proposer or Insured / Reinsured when seeking new insurance / reinsurance or renewing an existing Policy must disclose any information which might influence the Insurer / Reinsurer in deciding whether or not to accept the risk, what the terms should be, or what premiums to charge. Failure to do so may render the insurance / reinsurance voidable from inception and enable the Insurer / Reinsurer to repudiate liability.

Qatari Shareholding Company l Licensed by Qatar Central Bank l Capital QR 255,279,02 (paid in full) l C.R. 7095 T +974 44041111 l ktg@alkhaleej.com l www.alkhaleej.com l Toll Free 8005007

P.O. Box: 4555 Doha – Qatar l 76 Grand Hamad Avenue - Area 5 l Fax + 974 4443 0530

PaidDisclosure of Material Facts

Tel Fax: offices number of staff etc etc: 3 WHAT TRADE ASSOCIATIONS IS YOUR COMPANY A MEMBER OF: Name1: Qualifications1: Experience Years1: Name2: Qualifications2: Experience Years2: Name3: Qualifications3: Experience Years3: Name4: Qualifications4: Experience Years4: Name5: Qualifications5: Experience Years5: Name6: Qualifications6: Experience Years6: Name7: Qualifications7: Experience Years7: Number of Directors Senior Managers: Number of Clerical Employees: Number of NonClerical Employees: Others Please specify: Income past 12 MonthsRow1: Income Current 12 MonthsRow1: Income Next 12 MonthsRow1: What percentage of your annual income is derived fromRow1: North America: South America: Asia excl China: Australasia: Refrigerated Cargoes: Project Cargoes: Dangerous Goods: Household Goods: A Warehouse LocationsRow1: Services ProvidedRow1: Security at WarehouseRow1: A Warehouse LocationsRow2: Services ProvidedRow2: Security at WarehouseRow2: A Warehouse LocationsRow3: Services ProvidedRow3: Security at WarehouseRow3: A Warehouse LocationsRow4: Services ProvidedRow4: Security at WarehouseRow4: B Your VehiclesRow1: Cargo CarriedRow1: Delivery Status KMRow1: B Your VehiclesRow2: Cargo CarriedRow2: Delivery Status KMRow2: B Your VehiclesRow3: Cargo CarriedRow3: Delivery Status KMRow3: B Your VehiclesRow4: Cargo CarriedRow4: Delivery Status KMRow4: No of YearsOcean Freight ForwarderNVOC: Approx of TurnoverOcean Freight ForwarderNVOC: No of YearsCustoms Broker: Approx of TurnoverCustoms Broker: No of YearsLocal Carrier: Approx of TurnoverLocal Carrier: No of YearsAir Freight ForwarderAir Cargo Agent: Approx of TurnoverAir Freight ForwarderAir Cargo Agent: No of YearsIntransit Warehousing: Approx of TurnoverIntransit Warehousing: No of YearsPackagingConsolidating: Approx of TurnoverPackagingConsolidating: No of YearsRoad Haulier: Approx of TurnoverRoad Haulier: No of YearsOther please specify below: Approx of TurnoverOther please specify below: What CP forms are usedRow1: What CP forms are used to subcharterRow1: Through Transport BL: Combined Transport BL: Operations: Paid2004 2005: OS2004 2005: Total2004 2005: Paid2005 2006: OS2005 2006: Total2005 2006: Paid2006 2007: OS2006 2007: Total2006 2007: Paid2007 2008: OS2007 2008: Total2007 2008: Paid2008 2009: OS2008 2009: Total2008 2009: Paid2010: OS2010: Total2010: Text1: Text2: Text4: Text5: Text6: Text7: Text8: Text9: Electronics: Perishables: Perishables2: Electronics2: Group11: 1Group12: 2Group13: Choice1Group14: Choice1Group15: 2Group16: Choice1Group17: 2Group18: 2Group19: Choice1Group20: 4Group21: 4Text15: Text16: Text17: Email Website: Email Website2: Approx Tonnage: Approx No of TEUS: Approx Tonnage_2: Text11: Text3: Text10: Check Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: Off