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Insurance Short Form
Please fill the form below
1
Step 1
2
Step 2
Company Name/ DBA:
This field is required.Please enter value
Additional name insured:
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*
Role:
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Name:
First Name
Last Name
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This field is required.Please enter value
Email Id:
This field is required.Please enter value
Please enter valid email address
Mobile No:
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Invalid phone number.
The value must be less than or equal to 20
Are you currently insured:
Yes
No
Maybe
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*
What products/service do you sell:
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*
To what market sector do you sell:
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What are your standard Terms of Payment:
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The value allows only numbers !.
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
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Do you agree with longer terms (If yes, show the maximum terms):
Yes
No
N/A
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Please specify:
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Projected "Insured" Sales: (Please exclude any inter-company sales and letter of credit, or otherwise secured, sales from this figure):
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The value allows only numbers !.
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Total domestic sales:
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The value allows only numbers !.
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Total export sales:
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The value allows only numbers !.
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
DSO (Days Sales Outstanding):
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Attach a file of your top 20 buyers, including their legal name, complete address along with requested credit limit. This limit should be the maximum exposure you have to this customer at any one time:
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Selected file is Invalid. (only file type .doc,.docx,.xls,.xlsx,.pdf,.zip,.jpg,.png,.gif,.txt,.ppt,.pptx,.tif and 5 MB size allowed)
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Signature:
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Date:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
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