Shipping Carrier or Moving Company:
(The actual carrier who is transporting your goods. If you are using a freight broker
or moving broker and do not know which carrier, just put the broker name.)
Mode of Transport:
City: State: Country:
City: State: Country:
Did you obtain a Quote for this insurance policy by submitting the Quote form, by email
or by speaking direct with a P.A.F representative?
If Yes, please enter your Quote below:
Quoted Price: $ Quote #:
If the above is a Valid Quote, you will be charged this amount.
Click here to view the Online Rates
and How to Calculate Your Policy Charge
if you have NOT received a Quote from Us.
Payment: We do not process credit card transactions through the Internet. We have our own secure credit card terminals, in our offices, for safe processing. You may safely enter your credit card information below, because it is protected by our Secure SSL Encrypted Website Server and cannot be intercepted or seen by anyone. Your information will only be seen by us, on our Secure SSL Server, and then the transaction will be processed here in our office, instead of a 3rd party processing company. However, If you feel more comfortable, you may also call us to give your payment info. over the phone.
Credit Card: #:--- 3 or 4 Digit Security Code:
Your Credit Card has a 3 digit Security Code found on the back of your card, listed after your credit card number in the signature area. We request that you enter this code as an added security measure. The security code is circled in the example picture on the right. |
I authorize P.A.F to charge my credit card for the cost of this Cargo Insurance Policy, according to the
Quote I received from a P.A.F representative, plus a credit card
merchant fee of 4% of the quoted price with
a $5 minimum, or if NO quote received then the online rates and category definitions listed on the
"Online Insurance Rates" page on this website,
plus the credit card merchant fee. I agree not to charge-back any purchases for certificates/policies of insurance that have already been issued: YES
Please sign that you agree to the rate/policy charge and terms of the insurance coverage selected
by typing your name:
Credit Card Billing Address:
Please check this box if the billing address for the credit card is the same as above:
If it is the same, you can leave the fields below blank. If the billing address for the credit card
is different then the address at the top of the form, then please fill in the fields below.
Address: City: State:
Country: Zipcode/Postal Code:
Exact Name on Credit Card:
How did you hear about us:
If Other Company or Search Engine, Please enter Name:
Who from our company did you speak with?:
| (who assisted you via phone or email? If you were able to obtain all information|
and answers from our website, please select "No one/website" above. If you spoke with one of our executives via phone or email, please select their name above.) If you are a repeat client/regular customer, then please select
Letter of Credit Wording if Required by bank or other (Optional):
If you have any other details you wish to provide you may do so in the comments box above. If you were given a quote over the phone, you may enter it here along with the name of the representative who provided the quote. |
Our site is secured
by a 256 bit SSL certificate. SSL stands for Secure Sockets Layer and is the Internet's leading Security Protocol, designed to prevent the interception of private or sensitive information sent over the Internet
and or computer network (i.e.: protection against hackers). SSL enables encrypted, authenticated communications across the internet ensuring that all online communications are secure and cannot be intercepted while in transit. Please be assured that any information you submit on our site will be
encrypted and protected by our SSL secured Web Server. Click
image above to verify our SSL certificate is active and valid.
Terms and Conditions of Insurance Coverage
I have Read and Agree to the Terms and Conditions of Insurance Coverage Yes
By submitting this application order form you
agree that you have:
1) Read, understand and agree to the
terms and conditions of coverage in the link
2) Viewed the category definitions table, linked
above, to select the correct category of your items.
3) If you did not obtain a quote directly from
P.A.F, then you agree that you have viewed the online rates chart
(linked at the top of this form) and have calculated your
policy charge. In absence of a valid quote, this is the
amount that will be charged to your credit card today for the purchase of this insurance coverage/policy.