Insurance High Value Application

INSURANCE HIGH VALUE APPLICATION

Applicant / Insured Information

Applicant Name:

Is the primary residence the insured risk address? Yes No

Policy Details

Policy Period: From to

Scheduled Property — High Value Items

List each high value item to be scheduled. Attach certified appraisals where required. Include provenance for art and serial numbers for jewelry and watches.

Coverage Options (select all that apply)

All-risk (open peril) coverage

Named perils only

Replacement cost valuation

Agreed value endorsement

Worldwide transit and exhibition coverage

Theft protection including jewelry-specific safeguards

Exclusions and Limitations

The insurer will not provide coverage for loss or damage attributable to: willful misconduct; ordinary wear and tear; gradual deterioration; nuclear hazard; war and civil commotion; dishonest or criminal acts by the insured or by members of the insured's household unless otherwise specifically endorsed. Coverage for flood, earthquake, and named governmental confiscation are excluded unless specifically added by endorsement.

The insured must maintain the property per any agreed safeguarding conditions. Failure to comply with agreed security, storage, maintenance, or appraisal requirements may result in denial of a claim or adjustment of benefit.

I acknowledge that I have read and understand the exclusions and limitations above:

Prior Losses / Claims History

Yes No

Beneficiary Designation

Designate payee or beneficiary for policy proceeds (if applicable). Percentages must total 100% when more than one beneficiary is named.

Documentation Checklist

Please indicate which supporting documents are attached:

Certified appraisals for scheduled items

Photographs showing condition and provenance

Proof of purchase / invoices

Police reports (for prior loss incidents)

Declaration, Authorization and Fraud Warning

I declare that the statements contained in this application are true, complete and correctly recorded to the best of my knowledge and belief. I understand that any material misrepresentation or omission made with the intent to deceive the insurer may render the policy void and may subject me to civil or criminal penalties including denial of coverage and recovery of amounts paid.

I authorize the insurer and its representatives to obtain information necessary to underwrite this application, including appraisal reports, insurance loss history, and to inspect or request photographs of the scheduled property. I further authorize release of information to third parties as reasonably necessary for claim handling, underwriting, and regulatory reporting.

I acknowledge that coverage is subject to the terms, conditions, endorsements and exclusions of the policy issued. Premium, deductibles, and limits are subject to change upon review of supporting documentation and inspection results.

Signature and Certification

By signing below I certify that the information provided in this application and all attachments is complete and accurate. I understand that submission of false information is a material misrepresentation and may result in rescission of coverage or other remedies permitted by law.

Sign Now