Proposal Form for International Movement of Household Goods & Vehicles
   *Name of the Insured *Orgin City, Country *Date
    *Destination
*Moving By (check one)


  *Email Address
*Currency Type
   * Required Fields
 
IMPORTANT - Please read carefully the notes below.
  i)It is important to reiterate that you must declare the full replacement value of the goods at destination as the policy is subject to average and you will have to bear a proportionate part of any loss or damage to articles not insured for their full replacement value. Please remember that replacement value at destination may be more than in the country of origin. For your convenience, an inflation factor has been added at the bottom of the form. By inserting the inflation factor, the adjusted value will automatically be calculated.
 
               
 
A- Electronic Components
Article No Items  Value  Article  No. Items Value 
Television   Pre-Recorded Video Tapes
Home Computer PC Blank Tapes/Cassettes
Software Compact Discs
Projection Screen TV   Speakers
Stereo Amplifier  Clock Radio/Alarm
Stereo Tuner  Washing Machine
Cassette/Player/Recorder  Dryer
Video Camera Refrigerator
VHS Video Recorder/Player  Freezer
CD Player Dishwasher
Turntable Cooker
Video Game Unit Food Processor
Video Games Assorted Telephone
Record Albums Other Electrical Items
Total $
 
 
B - CHINA / GLASSWARE
Article No Items Value Article No Items Value
Total $
C - SILVER / COLLECTABLES
Article No Items Value Article No Items Value
Total $
               
D - MISCELLANEOUS
Article No Items Value Article No Items Value
Cameras Sewing Machine
Camera Accessories Sewing Accessories
Movie Camera Musical Instruments
Holiday Decorations Pictures
Religious Ornaments Lamps(s)
Piano Mirror(s)
Clocks Binoculars
Total $
           
E - HIGH VALUE ITEMS
Article No Items Value Article No Items Value
Antiques Pictures/Paintings
Total $
             
F - DINING ROOM
Article No Items Value Article No Items Value
Table Chair(s)
Rug(s) - Carpet(s) Lamp(s)
Shelving Units
Total $
             
G - LIVING ROOM
Article No Items Value Article No Items Value
Sofa(s) Drapes
Chair(s) Piano Bench
Sidetable(s) Coffee Table
Desk Shelving Units
Rug(s) - Carpet(s) Lamp(s)
Total $
               
H - FAMILY ROOM \ LIBRARY \ DEN
Article No Items Value Article No Items Value
Paperback Books Rug(s) - Carpet(s)
Hardcover Books  Desk
Children's Books Drapes
Reference Books Toys
Chair(s) Games
Sofa(s) Writing Bureau
Table(s) Shelving Units
Total $
               
I - KITCHEN
Article No Items Value Article No Items Value
Table Pots and Pans
Chair(s) Bowls etc.
Dishes Units
Utensils
Total $
               
J - MASTER BEDROOM #1
Article No Items Value Article No Items Value
Chairs(s) Chest of Drawers
Bed(s) Rug(s)
Bedside Table Drapes
Dressing Table Desk
Total $
               
K - BEDROOM #2
Article No Items Value Article No Items Value
Bed(s) Dresser/Chest of Drawers
Chairs(s) Rug(s)
Bedside Table Drapes
Total $
               
L - BEDROOM #3
Article No Items Value Article No Items Value
Bed(s) Dresser/Chest of Drawers
Chairs(s) Rug(s)
Bedside Table Drapes
Total $
               
M - OTHER BEDROOM(S)
Article No Items Value Article No Items Value
Bed(s) Dresser/Chest of Drawers
Chairs(s) Rug(s)
Bedside Table Drapes
Total $
               
N - LINENS / BATHROOM ITEMS
Article No Items Value Article No Items Value
Pillows Quilts
Pillow Cases Table Cloths
Sheets Towels
Blankets Medicine Cabinet
Bed Spreads Duvet
Total $
               
O - PATIO / GARDEN
Article No Items Value Article No Items Value
Table Barbecue
Chairs(s) Barbecue Accessories
Sun Shades
Total $
                  
P - CLOTHING
Article No Items Value Article No Items Value
Suits Sleepwear
Dresses Shoes/Boots
Formal Wear Ties
Sports Coats Undergarments
Trousers/Pants Lingerie
Sweaters/Jumpers Hats
Skirts Coats
Blouses Gloves
Shirts Purses
Socks/Hosiery
Belts
Total $
                 
Q - BASEMENT / ATTIC / GARAGE
Article No Items Value Article No Items Value
Smoke Detectors Golf Clubs
Iron Sporting Equipment
Ironing Board Lawn Mower
Work Bench Garden Tools
Power Tools Hose
Hand Tools Exercise Equipment
Tool Box Bicycles
Total $
               
PAIRS AND SETS*
(This coverage will not be included unless additional insurance is purchased to cover these items.)
Article No Items Value Article No Items Value
Total $
           
MECHANICAL AND ELECTRICAL DERANGEMENT*
(This coverage will not be included unless additional insurance is purchased to cover these items.)
Article No Items Value Article No Items Value
Total $
SUMMARY
A - Electrical Components  
B - Fine China / Glassware  
C - Silver / Collectibles  
D - Miscellaneous  
E - High Value Items  
F - Dining Room  
G - Living Room  
H - Family Room / Library / Den  
I - Kitchen  
J - Bedroom #1 / Master  
K - Bedroom #2  
L - Bedroom #3  
M - Other Bedroom(s)  
N - Linens / Bathroom Items  
O - Patio / Garden  
P - Clothing  
Q - Basement / Attic / Garage  
Pairs and Sets*  
Mechanical and Electric*  
SUBTOTAL  
MOVING CHARGES  
TOTAL VALUE  
INFLATION FACTOR AT DESTINATION**  
ADJUSTED TOTAL VALUE AT DESTINATION  
               
MOTOR VEHICLES
Separate Certificate Will Be Issued
Subject to issue of pre-shipment vehicle condition report.
Make(s)
Model(s)
Year(s)
Value(s)
 
  *This coverage will not be included unless additional insurance is purchased to cover these items. **Enter an inflation factor at destination from 1.00 - 5.00. Please convert percentages to decimals. For example 135% = 1.35.              
    By checking this box, I declare that I have disclosed all material facts and that failure to do so could render the insurance void. I declare that the amounts stated above are the full values of the goods at destination. I have read the terms and conditions of insurance associated with this form, and understand that these will form the basis of the proposed contract between me and the insurers.  
 
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© 1999 North American Van Lines, Inc.