Insurance Valuables Application

Insurance Valuables Application

Applicant / Insured Information

Applicant Name:    Date of Birth:

Phone:    Email:    Last 4 of SSN/Tax ID:

I certify that I am the sole legal owner of the items listed.

Policy Details Requested

Scheduled Jewelry    Fine Art    Collectibles    Electronics    Other

Total Coverage Requested: $    Deductible: $    Estimated Premium: $

Policy Period From:    To:

Coverage Options

Theft    Accidental Damage    Mysterious Disappearance    Worldwide Coverage    Transit / Shipping Coverage

Appraisal required for items with requested coverage over $5,000

Itemized Schedule of Valuables

Provide a complete description for each item. Attachments, photographs and appraisals must be retained and presented upon request.

Year:    Serial / ID No.:    Appraised Value: $    Requested Coverage: $

Appraisal attached    Photographs attached    Receipt available:

Year:    Serial / ID No.:    Appraised Value: $    Requested Coverage: $

Appraisal attached    Photographs attached    Receipt available:

Year:    Serial / ID No.:    Appraised Value: $    Requested Coverage: $

Appraisal attached    Photographs attached    Receipt available:

Year:    Serial / ID No.:    Appraised Value: $    Requested Coverage: $

Appraisal attached    Photographs attached    Receipt available:

Beneficiary / Loss Payee

List any designated payee(s) for proceeds of a covered loss.

Relationship:    Percentage: %

Relationship:    Percentage: %

Documentation Checklist

Please indicate which supporting documents are attached with this application:

Photographs of items    Formal appraisals    Purchase receipts    Police report (if applicable)

Exclusions and Important Notices

The insurer will not be liable for loss or damage arising from wear and tear, gradual deterioration, mechanical breakdown, war, nuclear hazard, or intentional acts by the insured. Coverage for mysterious disappearance, transit, and worldwide risks is subject to specific policy language and limits. High-value items may be subject to agreed value, appraisal requirements, and separate endorsements. Applicants must disclose prior damage, prior claims, and any existing liens.

I acknowledge that I have read and understand the exclusions and limitations described above.

Declarations and Certification

By signing below, I declare under penalty of perjury that the information provided in this application is true, complete and correct to the best of my knowledge. I authorize the insurer and its representatives to obtain appraisals or inspections, to verify any statements made in this application, and to review prior loss history. I understand that any material misrepresentation or omission may result in denial of coverage or rescission of the policy. I agree that coverage, if issued, will be governed by the policy terms, conditions, endorsements and exclusions.

I understand that acceptance of this application and issuance of a policy is subject to underwriting review. Premium and deductible amounts will be set by the insurer and confirmed in the policy schedule. I understand that appraisal documentation may be required prior to binding coverage for items with high requested limits.

I certify the foregoing and request the insurer to quote coverage based on the information provided.

Inspection and Arbitration

The insurer reserves the right to inspect items listed on this application. Disputes arising from coverage determinations or claims adjustments may be subject to the policy's arbitration clause where applicable. Notice of claim must be provided promptly in accordance with the policy.

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