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PRIVATE ART COLLECTORS POLICY - PROPOSAL FOR INSURANCE

 PLEASE ANSWER ALL QUESTIONS

Period of Policy Desired: From: To:



Section 1. - Details of Proposed Assured:

a. Name of Proposed Assured (state in full):
b. Residential Address(es):
c. At which address(es) are the items to be insured located:
d. Business or Occupation of Proposer:

e. State all losses (insured or uninsured) during the past 5 years:

f. Has any insurer ever cancelled or refused to issue or continue any insurance for you?
If yes, give Company name and reason below:


Section 2. – Sums Insured required:

1. State Values to be insured:
(PLEASE ATTACH A FULL SCHEDULE OF ITEMS)
Paintings, Drawings, Prints etc. Total US$
Sculpture (Bronze, Metal, Wood). Total US$
Sculpture (other media.) Total US$
Furniture and the like. Total US$
Porcelain or Fragile items. Total US$
Other (please specify). Total US$
TOTAL SUM INSURED. US$

NOTE: All items should be listed separately showing the value of each item. A professional Valuation will be required.

2. If there is any exposure away from Assured’s premises please specify:


Section 3. – Details of Premises and Protection:

Please competed this section for each location:

1. Premises:

Are the premises an Apartment:
If YES is it self contained:

YES/NO

On what floor of the building is it situated:

If the premises are not an Apartment please specify
Premises Construction:
Age:
Floor Level:
Residential or Commercial area:
2. Protection:
Burglar Alarm with Central Station: YES/NO
Name of Company:
Burglar Alarm Other: Please specify details.
Fire Alarm: YES/NO
Heat/Smoke detectors: YES/NO
Any other protections: Please specify:
3. Will the premises at which the items to be insured are located be regularly left unattended by day or by night: YES/NO
If YES please outline details.

Section 5. – Additional Information:

1. Any other material fact (please state):
(N.B. a material fact is one that is likely to influence acceptance of this risk by Underwriters).


Signing this proposal and declaration does not bind the Proposer to complete the insurance, but it is agreed that this proposal and declaration shall constitute a warranty should it be issued.

Signature of Proposer: ________________________________________________________
Name: ________________________________________________________
Date: ________________________________________________________