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Insurance form for shipment of household goods

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Insurance form for shipment of household goods Powered By Docstoc
					                                                   INSURANCE FORM - HHG & P/EFF

                                 Proposal For Shipment of Household Goods and Personal Effects

Proposer :

Address at Origin :

Address at Destination :




Mode of Shipment by (Please Tick) : Sea (Full Container)                     Sea (Part Container)                           Air            Land

Packing (Please Tick)                  : Professional                        Self (Restricted cover only)

Approx. commencement date of transit:                                                       No of packages:

Packing Company's Name                 :



All items should be insured for present day market value at destination. Failure to do so will result in valuation clause to be applied.
All items being shipped must be declared for insurance.
Describe each item and give individual values. Please give details of each set.

   A.                              LIVING ROOM
                                                                                                                             Replacement
  No.    ARTICLES                    No. Items           Replacement cost         No.       ARTICLES               No. Items cost
   1     Sofas                                                                    15        Refrigerator
   2     Chairs                                                                   16        Freezer
   3     Lamps & Shades                                                           17        Vacuum Cleaners
   4     Tables                                                                   18        Washing Machine
   5     Radios                                                                   19        Dryer
   6     TVs                                                                       E                      CHINAWARE/PORCELAIN
   7     Rugs & Carpets                                                            1
   8     Curtains                                                                  2
   9     Piano & Musical Instruments                                               3
  10     Bookcase / Wall Unit                                                      4
  11     Cupboards                                                                 5
  12     Hi-Fi system/Home Theatre                                                 6
  13     Pictures & Paintings
  14     Video Recorder/DVD                                                        F                           CRYSTAL/GLASSWARE
                                                                                   1
   B                               DINING ROOM                                     2
   1     Tables                                                                    3
   2     Chairs                                                                    4
   3     Cupboards                                                                 5
   4     Sideboard                                                                 6
   5     Lamps & Chandeliers
   6     Rugs & Carpets                                                            G                          SILVERWARE/BRASSWARE
   7     Curtains                                                                  1
   8     Mirrors                                                                   2
   9     Table Linen                                                               3
   10    Pictures & Paintings                                                      4
   11    Desk                                                                      5
                                                                                   6
   C                              FAMILY ROOM
   1     Chairs                                                                    H                          ANTIQUES / WORK OF ART
   2     Curtains                                                                  1
   3     Sofas                                                                     2
   4     Tables                                                                    3
   5     Lamps/Shades                                                              4
   6     Rugs & Capets                                                             5
   7     Desk                                                                      6
   8     Bookcases
   9     Pictures & Paintings                                                      I                            SPORTS EQUIPMENT
   10    Cupboard(s)                                                               1
                                                                                   2
   D                                  KITCHEN                                      3
   1     Tables                                                                    4
   2     Chairs                                                                    5
   3     Electrical Appliances                                                     6
   4     Cabinets
   5     Kitchen Linen                                                             J                             LINEN / CLOTHING
   6     Dishwater                                                                 1        Coats / Jackets
   7     Oven/Cooker                                                               2        Suits
   8     Microwave                                                                 3        Dresses
   9     Dishes                                                                    4        Trousers
   10    Utensils / Cutlery                                                        5        Sweaters
   11    Pots & Pans                                                               6        Blouses
   12    Bowls, Trays Etc                                                          7        Skirts
   13    Plastic/Tupperware
   14    Food Processor
                                                                                 INSURANCE FORM - VEHICLE

                                                                          Proposal for Shipment of Private Motor Vehicles

Proposer : ____________________________________________________________________________________________________________________________________________________

From: ___________________________________________________________________                                         To: _______________________________________________________________
Shipped By                         :       SEA                                                           If by sea shipped in full container:                     Yes                 No
                                           AIR                                                           Approx. commencement date of transit:                               /    /
                                           ROAD


Vehicle Make/Model :                                _______________________________________                       Year               :
                                                                                                                                  _______________________________________

Chassis No.               :                         _______________________________________                       Engine No.       :
                                                                                                                                  _______________________________________

Mileage                       :                     _______________________________________                                    :
                                                                                                                  Sum Insured _______________________________________


Please indicate cover required: Full Conditions (subject to inspection report)                                                    Restricted Conditions

DAMAGE IDENTIFICATION CODE CHART
A - Bent             E - Chipped                    J -Stained
B - Broken           F - Cracked                    K - Scratched
C - Cut              G - Missing
D - Dented           H - Scuffed

INSTRUCTIONS

1. Enter Damage Code Letter next to appropriate item
2. Explain all excessive exceptions in the remarks section
3. Enter damage in centimetres (in column entitled "Area in cms") whenever such designations are applicable


                                  DAMAGE              AREA IN                                                                                                       DAMAGE             AREA IN
                                   CODE                CMS                              DAMAGE CODE               AREA IN CMS                                        CODE               CMS
    Antenna (Radio C.B)                                           Front Grille                                                    Wheel and Tyre, Left Front
Bumper, Front                                                     Headlight Left                                                  Wheel and Tyre, Left Rear
Bumper, Rear                                                      Headlight Right                                                 Wheel and Tyre, Right Front
Bumper Guard, Front                                               Roof - Exterior                                                 Wheel and Tyre, Right Rear
Bumper Guard, Rear                                                Wing Mirror - Right                                             Wheel and Tyre, Spare
Door, Left Front                                                  Wing Mirror - Left                                              Front Windscreen
Door, Left Rear                                                   Window Left Front                                               Rear Windscreen
Door, Right Front                                                 Window Right Front                                              Windscreen Wiper Front
Door, Right Rear                                                  Window Left Rear                                                Windscreen Wiper Rear
Hatch Back                                                        Window Right Rear                                               Other remarks
Wing Left Front                                                   Bonnet and badge
Wing Left Rear                                                    Boot
Wing Right Front                                                  Tail Light Left
Wing Right Rear                                                   Tail Light Right

REMARKS (Please continue over if insufficient space)
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________


Declaration: I declare that the details herein are correct according to the best of my knowledge and belief and agree that the particulars and statements given shall form the basis of the
contact between us.




                                                                                                                                   Surveyed on behalf of underwriters by:


Owner's signature:                                                Date:                                           Surveyor's signature:


                                                                                                                  Date:

				
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