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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