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