Insurance Jewelry Application

INSURANCE JEWELRY APPLICATION

Applicant / Insured Information

Applicant Name:

Date of Birth:    Social Security / Tax ID (if required):

Policy Details

Policy Type: Scheduled Items    Blanket Coverage (all eligible jewelry)

Policy Period From:    To:

Itemized Jewelry Schedule

List all items to be insured. Attach appraisals and photographs where available. If additional space is required, attach a separate schedule with identical column information and sign the attachment.

Coverage Options

Select desired coverages (additional premium may apply):

All-Risk Coverage (subject to policy exclusions)    Named Perils Only

Worldwide Coverage    In-Transit Coverage    Mysterious Disappearance Coverage

Exclusions (Representative)

Unless expressly endorsed, this policy does not cover loss or damage caused by: wear and tear, gradual deterioration, inherent vice, mechanical or electrical breakdown, war, nuclear hazard, confiscation by authorities, or loss of market value. Coverage for mysterious disappearance, theft by domestic employees, or transit losses may be excluded unless specifically requested and underwritten. Fraudulent or intentionally false statements in this application are grounds for policy rescission and denial of claims.

Claims & Loss History

Have you or any proposed insured reported any loss related to jewelry or valuables in the last five (5) years? Yes No

Appraiser / Documentation

Appraisal Date:    Appraised Value (aggregate shown):

Documentation checklist:
Photographs attached    Original purchase receipts attached    Appraisals attached    Gemstone certificates attached

Beneficiary / Loss Payee

Declaration and Certification

I certify that the statements contained in this application are true and complete to the best of my knowledge and belief. I understand that any material misrepresentation, omission, or false statement may result in denial of coverage, rescission of any policy issued, or voiding of coverage for affected items.

I authorize the insurer and its representatives to make any inquiry, inspection, or appraisal of the items and documentation submitted in support of this application, including verification of purchase records and appraisal reports. I understand that coverage is subject to underwriting acceptance and the terms, conditions, limitations and exclusions of the policy issued.

I agree to notify the insurer of any material change in the description, value, location, or use of any insured item. I understand premiums are subject to adjustment and that claims are payable only as provided in the policy and after any deductible applied.

By signing below I declare under penalty of perjury that the foregoing statements are true and complete.

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