INSURANCE FORM

Proposal for Shipment of Household Goods and Personal Effects with AXAInsuranceGulf

  • All items should be insured for present day market value at destination. Failure to do so will result in valuation clause to be applied
  • Items declared but not valued are not insured
  • Cover is availible in respect of suitcases, trunks and similar items only if they are packed in an outer container
  • Cover is not available for bank notes, shares, deeds, jewellery, stamps, securities and negotiable instruments unless specially declared and cover agreed.

No / Articles / No Item / Replacement Cost / No / Articles / No Item / Replacement Cost
A. /

LIVING ROOM

/ C. / FAMILY ROOM
1 / Sofa(s) / 1 / Chair(s)
2 / Chair(s) / 2 / Curtains
3 / Lamp(s) & Shade(s) / 3 / Sofa(s)
4 / Table(s) / 4 / Table(s)
5 / Radios(s) / 5 / Lamps
6 / TV(s) / 6 / Rug(s) & Carpets
7 / Rugs(s) & carpets(s) / 7 / Desk
8 / Curtains / 8 / Bookcase(s)
9 / Piano or other musical / 9 / Pictures & Paintings
10 / Bookcase/Wall Unit / 10 / Cupboard(s)
11 / Cupboard(s)
12 / Hi-Fi System / D. /

KITCHEN

13 / Pictures & Paintings / 1 / Table(s)
14 / Video recorder / 2 / Chair(s)
3 / Electrical Appliances
B. / DINING ROOM / 4 / Cabinets
1 / Table(s) / 5 / Kitchen linen
2 / Chair(s) / 6 / Dishwasher
3 / Cupboard(s) / 7 / Oven
4 / Sideboard / 8 / Microwave
5 / Lamps & Chandeliers / 9 / Dishs
6 / Rug(s) & Carpets / 10 / Utensils/Cutlery
7 / Curtains / 11 / Pots & Pans
8 / Mirrors / 12 / Bowls, trays Ect
9 / Table Linen / 13 / Refridgerator
10 / Pictures & Paintings / 14 / Freezer
11 / Writing Bureau/Desk / 15 / Vacuum cleaners
16 / Washing machine
E. / CHINA / K / BEDROOM (MAIN)
1 / 1 / Bed(s)
2 / 2 / Chair(s)
3 / 3 / Table
4 / 4 / Dressing table
5 / 5 / Chest of drawers
6 / 6 / Mirrors
7 / Rug(s)
F. / GLASSWARE / 8 / Lamps
1 / 9 / Curtains
2 / 10 / Bookcases
3 / 11 / Wadrobe(s)
4
5 / L / BEDROOM(OTHERS)
6 / 1 / Bed(s)
2 / Chair(s)
G. / SILVER / 3 / Table
1 / 4 / Dressing table
2 / 5 / Chest of drawers
3 / 6 / Mirrors
4 / 7 / Rug(s)
5 / 8 / Lamps
6 / 9 / Curtains
10 / Bookcases
H / ANTIQUES/W O ART / 11 / Wardrobe
1
2 / M / BATHROOM(s)
3 / 1 / Rugs, Toilet covers
4 / 2 / Toiletries
5 / 3 / Medical Supplies
6 / 4 / Towel, ect
5 / Laundry basket
I / SPORTSEQUIPMENT / 6 / Perfume/aftershave
1 / 7 / Cabinets/shelves
2 / 8 / Mirrors
3 / 9 / Razors
4 / 10 / Hair dryer(s)
5
6 / N / MISCELLANEOUS
1 / Typewriter
J / LINEN/CLOTHING / 2 / Clock
1 / Coats/Jackets / 3 / Telephone/Fax
2 / Suit(s) / 4 / Plant Holders
3 / Dresses / 5 / Toys & games
4 / Sport coat / 6 / Food (non-perishable)
5 / Trouser / 7 / Computer
6 / Sweator / 8 / Computer printer
7 / Blouse / 9 / Computer supplies
8 / Skirt / 10 / Sewing machine
9 / Sleepwear / 11 / Video camera
10 / Shirt / 12 / Cameras/lens
11 / Footwear / 13 / Misc Camera equipment
12 / Hoisery/socks / 14 / Projectors
13 / Ties/scarves / 15 / Pictures/paintings
14 / Underwear / 16 / Bicycles
15 / Lingerie / 17 / Books
16 / Sportswear / 18 / Records
17 / Sheets / 19 / Tapes
20 / CDS
O / ANY OTHER ITEMS / Total Household Goods
Insured Value (UAE AED)______
Please list seperatly any item exceeding AED 1,850/-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Please tick cover required:Cover A (professionaly packed goods only)

All material facts must be disclosed, failure to do so could invalidate the policy. A material fact is one which would be likely to influence an insurer in the assesment and acceptance of the proposal. If in any doubt as to whether a fact is material then it should be discloded here.

Declaration I declare that the details herein are correct according to the best of my knowledge and belief and agree that the particulars and statements shall form the basis of the contract between us.

Date : / Proposer Signature :