* - Required Fields

IMPORTANT - Please read carefully the notes below.

(i)It is important to reiterate that you must declare the full replacement value of the goods at destination as the policy is subject to average and you will have to bear a proportionate part of any loss or damage to articles not insured for their full replacement value. Please remember that replacement value at destination may be more than in the country of origin. For your convenience, an inflation factor has been added at the bottom of the form. By inserting the inflation factor, the adjusted value will automatically be calculated.

A - ELECTRONIC COMPONENTS
Article	No.Item	Value		Article	No.Item	Value
Television				Pre-Recorded Video Tapes
Home Computer/PC				Blank Tapes/Cassettes
Software				Compact Discs
Projection Screen TV				Speakers
Stereo Amplifier				Clock Radio/Alarm
Stereo Tuner				Washing Machine
Cassette/Player/Recorder				Dryer
Video Camera				Refrigerator
VHS Video Recorder/Player				Freezer
CD Player				Dishwasher
Turntable				Cooker
Video Game Unit				Microwave
Video Games Assorted				Food Processor
Record Albums				Telephone
Pre-Recorded Tape Cassettes				Other Electrical Items
					Total $:

B - CHINA / GLASSWARE
Article	No.Item	Value		Article	No.Item	Value
					Total $:

C - SILVER / COLLECTABLES
Article	No.Item	Value		Article	No.Item	Value
					Total $:

D - MISCELLANEOUS
Article	No.Item	Value		Article	No.Item	Value
Cameras				Sewing Machine
Camera Accessories				Sewing Accessories
Movie Camera				Musical Instruments
Holiday Decorations				Pictures
Religious Ornaments				Lamps(s)
Piano				Mirror(s)
Clocks				Binoculars
					Total $:

E - HIGH VALUE ITEMS
Article	No.Item	Value		Article	No.Item	Value
Antiques				Pictures/Paintings
					Total $:

F - DINING ROOM
Article	No.Item	Value		Article	No.Item	Value
Table				Chair(s)
Rug(s) - Carpet(s)				Lamp(s)
Shelving Units
					Total $:

G - LIVING ROOM
Article	No.Item	Value		Article	No.Item	Value
Sofa(s)				Drapes
Chair(s)				Piano Bench
Sidetable(s)				Coffee Table
Desk				Shelving Units
Rug(s) - Carpet(s)				Lamp(s)
					Total $:

H - FAMILY ROOM \ LIBRARY \ DEN
Article	No.Item	Value		Article	No.Item	Value
Paperback Books				Rug(s) - Carpet(s)
Hardcover Books				Desk
Children's Books				Drapes
Reference Books				Toys
Chair(s)				Games
Sofa(s)				Writing Bureau
Table(s)				Shelving Units
					Total $:

I - KITCHEN
Article	No.Item	Value		Article	No.Item	Value
Table				Pots and Pans
Chair(s)				Bowls etc.
Dishes				Units
Utensils
					Total $:

J - MASTER BEDROOM #1
Article	No.Item	Value		Article	No.Item	Value
Chairs(s)				Chest of Drawers
Bed(s)				Rug(s)
Bedside Table				Drapes
Dressing Table				Desk
					Total $:

K - BEDROOM #2
Article	No.Item	Value		Article	No.Item	Value
Bed(s)				Dresser/Chest of Drawers
Chairs(s)				Rug(s)
Bedside Table				Drapes
					Total $:

L - BEDROOM #3
Article	No.Item	Value		Article	No.Item	Value
Bed(s)				Dresser/Chest of Drawers
Chairs(s)				Rug(s)
Bedside Table				Drapes
					Total $:

M - OTHER BEDROOMS(S)
Article	No.Item	Value		Article	No.Item	Value
Bed(s)				Dresser/Chest of Drawers
Chairs(s)				Rug(s)
Bedside Table				Drapes
					Total $:

N - LINENS / BATHROOM ITEMS
Article	No.Item	Value		Article	No.Item	Value
Pillows				Quilts
Pillow Cases				Table Cloths
Sheets				Towels
Blankets				Medicine Cabinet
Bed Spreads				Duvet
					Total $:

O - PATIO / GARDEN
Article	No.Item	Value		Article	No.Item	Value
Table				Barbecue
Chairs(s)				Barbecue Accessories
Sun Shades
					Total $:

P - CLOTHING
Article	No.Item	Value		Article	No.Item	Value
Suits				Sleepwear
Dresses				Shoes/Boots
Formal Wear				Ties
Sports Coats				Undergarments
Trousers/Pants				Lingerie
Sweaters/Jumpers				Hats
Skirts				Coats
Blouses				Gloves
Shirts				Scarves
Socks/Hosiery				Purses
Belts
					Total $:

Q - BASEMENT / ATTIC / GARAGE
Article	No.Item	Value		Article	No.Item	Value
Smoke Detectors				Golf Clubs
Iron				Sporting Equipment
Ironing Board				Lawn Mower
Work Bench				Garden Tools
Power Tools				Hose
Hand Tools				Exercise Equipment
Tool Box				Bicycles
Luggage
					Total $:

PAIRS AND SETS*
(This coverage will not be included unless additional insurance is purchased to cover these items.)
Article	No.Item	Value		Article	No.Item	Value
					Total $:

MECHANICAL AND ELECTRICAL DERANGEMENT*
(This coverage will not be included unless additional insurance is purchased to cover these items.)
Article	No.Item	Value		Article	No.Item	Value
					Total $:

SUMMARY
	A - Electrical Components
	B - Fine China / Glassware
	C - Silver / Collectibles
	D - Miscellaneous
	E - High Value Items
	F - Dining Room
	G - Living Room
	H - Family Room / Library / Den
	I - Kitchen
	J - Bedroom #1 / Master
	K - Bedroom #2
	L - Bedroom #3
	M - Other Bedroom(s)
	N - Linens / Bathroom Items
	O - Patio / Garden
	P - Clothing
	Q - Basement / Attic / Garage
	Pairs and Sets*
	Mechanical and Electric*
SUBTOTAL
MOVING CHARGES
TOTAL VALUE
INFLATION FACTOR AT DESTINATION**
ADJUSTED TOTAL VALUE AT DESTINATION

MOTOR VEHICLES
Separate Certificate Will Be Issued
Subject to issue of pre-shipment vehicle condition report.
Make(s)
Model(s)
Year(s)
Value(s)

*This coverage will not be included unless additional insurance is purchased to cover these items.
**Enter an inflation factor at destination from 1.00 - 5.00. Please convert percentages to decimals. For example 135% = 1.35.

By checking this box, I declare that I have disclosed all material facts and that failure to do so could render the insurance void. I declare that the amounts stated above are the full values of the goods at destination. I have read the terms and conditions of insurance associated with this form, and understand that these will form the basis of the proposed contract between me and the insurers.