Insurance Valuation Form

INSURANCE VALUATION FORM

This Insurance Valuation Form is used to record the insured's representations regarding the value and condition of property or insured items for underwriting, rating, or claims adjustment. Complete all fields fully and attach documentation requested in the Supporting Documentation Checklist. The undersigned certifies that the information provided is true, complete, and accurate to the best of their knowledge.

1. Applicant / Insured Information

2. Policy Details

Policy Type: Homeowners Renters Personal Articles Business Property

3. Valuation Methodology

Select the primary valuation basis applied to items listed below (check one). If multiple methods are used, indicate per item in the Itemized Section.

Replacement Cost Value (RCV) — cost to replace without deduction for depreciation
Actual Cash Value (ACV) — replacement cost less depreciation
Agreed Value — pre-determined agreed valuation between insured and insurer

4. Itemized Property / Assets

Provide a separate line for each item or group of like items. Attach additional sheets if necessary. For each item indicate the method of valuation if it differs from the primary method above.

5. Total Valuation Summary

Total Replacement Cost:   Total Depreciation:   Estimated Current Value:

6. Coverage Options

Select coverage options to be considered with this valuation (check all that apply):
Personal Contents Coverage
Scheduled Jewelry / Personal Articles Floater
Flood Coverage
Earthquake Coverage
Business Property Coverage
Increased Liability Limit

7. Exclusions and Limitations

The insurer's acceptance of valuation information is subject to policy language, terms, and conditions. The following are common exclusions unless otherwise endorsed: wear and tear, gradual deterioration, inherent vice, damage caused by vermin, loss arising from unreported prior damage, and losses excluded by statute or ordinance. Any endorsements or special limits will be applied at underwriting or claim payment.

Insured Initials Acknowledging Exclusions and Limitations:

8. Supporting Documentation Checklist

Include copies of the following where available. Failure to provide documentation may delay underwriting or claim settlement.
Original purchase receipts
Photographs of items and serial numbers
Qualified appraisals (for items of significant value)
Repair or replacement invoices
Police or incident reports (if applicable)
Prior valuations or schedules

9. Beneficiary Information (If Applicable)

Beneficiary Name:   Relationship:

Beneficiary Percentage Allocation:   Contact Info:

10. Additional Remarks

11. Declaration and Certification

I certify under penalty of perjury that the information provided on this form and in any attached documentation is true, correct, and complete. I understand that intentional misrepresentation or omission of material facts may constitute insurance fraud and may void coverage or result in denial of claims and criminal or civil penalties where applicable. I authorize the insurer or its authorized representatives to verify any information provided, including contacting third parties and reviewing available records, for purposes of underwriting, valuation, or claim investigation. I agree to cooperate with reasonable requests for additional information, inspection, or appraisal necessary to substantiate values set forth herein.

Signature Date:

Sign Now