"ALL RISK" INTERNATIONAL VALUATION PROTECTION APPLICATION FORM

1 Electronic Components
Article	QTY.	Value
Television(s)
Home Computer/PC
Software
LCD and/or Plasma TV
Stereo Components
Stereo Speakers
Video Camera
DVD/VCR
Video Game Unit
Video Games
CD's & DVD's
Videos
Clock Radio / Alarm






Category 1 - Subtotal:	$
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2 Appliances
Article	QTY.	Value
Washing Machine
Dryer
Refrigerator
Freezer
Dishwasher
Stove/Cooking Unit
Microwave
Toaster Oven
Coffee Maker
Food Processor






Category 2 - Subtotal:	$
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3 China / Glassware
Article	QTY.	Value







Category 3 - Subtotal:	$

4 Silver Collectibles
Article	QTY.	Value








Category 4 - Subtotal:	$

5 High value items
Article	QTY.	Value














Category 5 - Subtotal:	$
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6 Dining Room
Article	QTY.	Value
Table
Chair(s)
Rug(s) - Carpet(s)
Light Fixtures
Shelving Units
China Cabinet(s)
Buffet
Corner Cabinet
Side Table(s)
Pictures / Paintings
Wine Rack
Drapes







Category 6 - Subtotal:	$
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7 Living room
Article	QTY.	Value
Sofa(s)
Chair(s)
Side Table(s)
Desk(s)
Rug(s) - Carpet(s)
Drapes
Piano
Piano Bench
Wall Unit
Coffee Table(s)
Shelving Units
Light Fixtures
Pictures / Paintings
Lamp(s)
Floor Lamp(s)








Category 7 - Subtotal:	$
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8 Family Room / Library / Den
Article	QTY.	Value
Paperback Books
Hardcover Books
Children's Books
Reference Books
Chair(s)
Sofa(s)
Table(s)
Rug(s) - Carpet(s)
Desk
Drapes
Toys
Games
Shelving Units
Fireplace Equipment
Pictures / Photos
Ottoman






Category 8 - Subtotal:	$
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9 Kitchen
Article	QTY.	Value
Table
Chair(s)
Dishes
Utensils
Pots & Pans
Bowls, etc.
Microwave Stand
Corner Cabinet
Side Table(s)
Stools
Pictures / Paintings
Buffet / Hutch






Category 9 - Subtotal:	$
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10 Patio Garden
Article	QTY.	Value
Lawn Table
Stacking Chairs
Barbeque
Barbeque Accessories
Umbrella
Lounge Chair(s)
Outdoor Equipment
Outdoor Toys
Buffet





Category 10 - Subtotal:	$
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11 Linen / bathroom Items
Article	QTY.	Value
Towels
Pillows
Pillow Cases
Sheets
Blankets
Bed Spreads
Quilts
Duvets
Table Cloths
Medicine Cabinet
Toiletries
Linens




Category 11 - Subtotal:	$
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12 Clothing
Article	QTY.	Value
Suits
Dresses
Formal Wear
Sport Coats
Trousers / Pants
Sweaters/ Jumpers
Skirts
Blouses
Shirts
Socks/Hosiery
Sleepwear
Shoes/Boots
Ties
Undergarments
Lingerie
Hats
Coats Gloves
Scarves



Category 12 - Subtotal:	$
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13 Bedroom #1
Article	QTY.	Value
Chair(s)
Bed(s)
Side Table(s)
Dressing Table(s)
Chest of Drawers
Rug(s)-Carpet(s)
Drapes
Desk(s)
Picture(s) / Painting(s)
Mirrors
Exercise Equipment
Lamp(s)
Toys
Clothes
Books



Category 13 - Subtotal:	$
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14 Bedroom #2
Article	QTY.	Value
Chair(s)
Bed(s)
Side Table(s)
Dressing Table(s)
Chest of Drawers
Rug(s)-Carpet(s)
Drapes
Desk(s)
Picture(s) / Painting(s)
Mirrors
Exercise Equipment
Lamp(s)
Toys
Clothes
Books

Category 14 - Subtotal:	$
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15 Bedroom #3
Article	QTY.	Value
Chair(s)
Bed(s)
Side Table(s)
Dressing Table(s)
Chest of Drawers
Rug(s)-Carpet(s)
Drapes
Desk(s)
Picture(s) / Painting(s)
Mirrors
Exercise Equipment
Lamp(s)
Toys
Books
Clothes

Category 15 - Subtotal:	$
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16 Other Bedrooms
Article	QTY.	Value
Bed(s)
Chair(s)
Side Table(s)
Dresser / Chest of Drawers
Rug(s) - Carpet(s)
Drapes
Desk(s)
Picture(s) / Painting(s)
Lamp(s)
Books
Posters
Peg Board
Stuffed Animals



Category 16 - Subtotal:	$
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17 Basement / Attic / Garage
Article	QTY.	Value
Smoke Detectors
Ironing Board
Work Bench
Power Tools
Hand Tools
Tool Box
Golf Clubs
Sporting Equipment
Lawn Mower
Garden Tools
Hose(s)
Exercise Equipment
Bicycles









Category 17 - Subtotal:	$
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18 Miscellaneous
Article	QTY.	Value
Camera(s)
Camera Accessories
Video Camera(s)
Holiday Decorations
Ornaments
Clocks/Grandfather Clock
Sewing Machine
Musical Instruments













Category 18 - Subtotal:	$
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19 Motor vehicle
Article	QTY.	Value
Make
Model
Year




Category 19 - Subtotal:	$
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All Category Subtotal

Additional Coverage Items

Grand Total

Select Currency	US$ CDN$ Other $

Please value my shipment for: $

Date (MM/DD/YYYY):

Print Name: *

I have read and fully understand and agree to the
Terms and Conditions of the coverage stated in this application, plus I agree to the stated acknowledgements on the "Inventory and Conditions of Articles Form".

Also email this form to:

Name	*
Origin	*	Destination	*
Check one	Land Sea Air Storage
How to complete this valued inventory: 1. Declare full replacement cost at destination. 2. Provide individual values for each item. 3. List all high value articles over $10,000 in value 4. Items not declared and valued are not covered 5. This policy does not insure valuables, such as jewellery, currency, coins, stamps, securities, etc. 6. All articles are subject to the Terms and Conditions Click below links to jump to the relevant categories:

1 Electronic Components	7 Living Room	13 Bedroom 1
2 Appliances	8 Family Room/Library/Den	14 Bedroom 2
3 China/Glassware	9 Kitchen	15 Bedroom 3
4 Silver Collectibles	10 Patio Garden	16 Other Bedroom(s)
5 High Value Items	11 Linen/Bathroom Items	17 Basement/Attic/Garage
6 Dining Room	12 Clothing	18 Miscellaneous
		19 Motor Vehicle