QUESTIONNAIRE For Cargo Insurance. 1. General Details of the Insured / Proposer. 2. Particulars of Goods

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1 1. General Details of the Insured / Proposer Full name: Registration address: Postal address: Contact person: Phone: Fax: Main line of business: Other lines of business: Beneficiary Full name: Registration address: Postal address: Contact person: Phone: Fax: In case of Letter of Credit payment, please, specify Letter of Credit For the amount of : In the name of: Bank: 2. Particulars of Goods 2.1 Please describe the goods to be insured 2.2 Are the goods to be shipped new or second hand 2.3 Are the goods to be shipped fresh, chilled of frozen Yes No If Yes, please specify 2.4 Will any of the goods be shipped in bulk Yes No If Yes, please specify which goods 2.5 For goods not shipped in bulk will they be packed Yes No If Yes, Please specify the packaging Cargo packaging type In Carton Boxes In Crates In Wooden casks In Steel casks In Glass Bottles

2 2.5.6 In Plastic bottles In Bags Placed on Pallets Fully loaded container Partly loaded container Other method 2.6 Will the good be shipped in fully enclosed shipping container Yes No If No, how will the goods be shipped 2.7 Are any of the goods to be insured overheight or overwidth and will not fill into fully enclosed containers Yes No a type which requires special lifting apparatus for loading and unloading Yes No required to be kept within a specific temperature range Yes No a type which requires replenishment of refrigerant if the voyage exceeds 12 hours Yes No fragile Yes No susceptible to rust, oxidisation or discolouration Yes No subject to an on deck bill of lading Yes No 2.8 If Yes to any of 7 above please specify what special instructions are given to packers, shipping and forwarding agents, and carries for the safe carriage of these goods 3. Voyage / Conveyances Trade Terms/Delivery Terms EXW FCA FAS FOB CRF CIF CPT CIP DAF DES DEQ DDU DDP From Intended date of departure / / To (final destination) Port of discharge if not final destination

3 Will goods be transhipped Yes No If Yes, where Goods shipped by Sea Air Rail Road Name of vessel Voyage of the vessel Age of Vessel Bill of Lading Flag Ship register Tonnage Name of airline Airway bill Railway bill Wagons Open wagons Tent wagons Containers Railway tanks Carriers Own vehicles Way bill Registration 4. Type of Coverage 4.1 Do you require All Risks cover relating to the goods to be insured Yes No If No, please specify the level of cover you require Please note that in certain circumstances All Risks cover may not be available. Our quotation will fully detail the cover we are able to provide. 4.2 Do you have any specific cover requirements Yes No

4 4.3 Do you wish to bear an excess (in addition to any compulsory excess which may apply Yes No If Yes, what is the level 5. Sum Insured, Valuation Sum insured is based on: Commercial invoice price Yes No If No, Please specify 5.1 Sum Insured 5.2 Additions to the Sum Insured 10% Freight Customs Duty (if required) Import Levy (if required) Yes No Other costs, please, specify 5.3 Goods in transit Invoice value Yes No If No, please specify 5.4 Please state the maximum value of goods any one conveyance

5 6. Declaration & Financial Details Value of insured goods Yes No 6.1 Do you require an annual policy where your declaration is on Sales turnover Yes No Monthly Yes No 6.2 Do you require an open cover where you will declare Each shipment Yes No 6.3 Please estimate the values to be declared for the next full year using the basis of valuation in 5 above 6.4 Claims history (last 3 years plus current year) Value of claims paid and outstanding Number of claims Year 20 Year 20 Year 20 Year 20 If actions have been taken to reduce claims, please specify 6.5 Previous insurance history Has any insurer declined insurance or imposed special terms Yes No If Yes, please specify The information stated in that questionnaire by the applicant is reliable and true. If, after signing of the insurance contract, it turns out that the Insured provided false and doubtful information, IngoNord reserves the right to act in accordance with the legislation of Finland.