UNACCOMPANIED HOUSEHOLD AND PERSONAL EFFECTS INSURANCE PROPOSAL

(MARINE TRANSIT RISKS)

Name of Proposer
Email Address
Present Address Please tick
address to
which Policy
is to be sent
Forwarding Address
ARTICLES TO BE INSURED
*Full Value *Full Value
Soft Goods Television Receivers
Clothing Cameras, Projectors and
Photographic Equipment
Carpets Gas and Electric Appliances
Silverware, Cutlery, Jewellery Other Musical Instruments
Sewing Machines Chinaware, Glassware and Similar Fragile Articles
Radios, Tape Recorders, Record Players Other Items
c/f TOTAL SUM TO BE INSURED $
Please detail and value (a)any single item over $500
                                   (b)all antique articles		 which have been included in the total sum to be insured.
  • i.e. the amount nesessary to replace the said articles to their present value.

PACKING
State whether the articles have been professionally packed (see exclusion 2 on the cover page)
State by whom packed
Give number and description of packages
Have the articles been in store prior to commencement of transit?      Yes    No
If so, for how long?

INSURED TRANSIT
From To
Name of vessel Approximate date of sailing
State whether cover is required for any period of intentional storage either before shipment or after arrival at destination (other then whilst at packer's premises during ordinary course of packing)

DECLARATION

I declare that to the best of my knowledge and belief the particulars and answers are true and complete and I agree that this proposal shall be the basis of a contract of insurance to be expressed in the usual terms of the Policy issued by the United Insurance Company Limited.
Dated
Agent's No.       Agent