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EXECUTIVE INSURANCE SERVICES
 
APPLICATION and DECLARATION 

for insurance coverage of household goods and personal effects
IMPORTANT: This is not an Insurance Certificate

APPLICATION and DECLARATION 
If you elect to insure your shipment for replacement cost, all items must be noted and valued. 
Items not listed on the valued inventory are not insured. Under no circumstances will coverage attach for more than the value noted. If you do not complete a valued inventory, your shipment will be covered for actual cash value, which is replacement cost less depreciation. Both options are subject to 100% co-insurance. Items grouped together are considered to be of equal value.

This information is being sent to your mover via email. Their email address is required.

NAMED INSURED     PICK UP DATE
MOVER'S NAME     ORIGIN
MOVER'S EMAIL     DESTINATION
DEDUCTIBLE      
MODE OF SHIPMENT   Land Sea Air      

QTY

ARTICLES OWNED
VALUE
 

LIVING ROOM

 

Bookcase

Bookshelves. Sectional

Chair, Arm

Chair, Occasional
Chair, Overstuffed
Chair, Rocker
Chair, Straight
Clock, Grandfather / Grandmother
Clock, Table
Curtains / Drapes
Desk
DVD Player(s)
Entertainment Center
Fireplace Equipment
Figurines
Foot Stool
Hide-a-bed, Studio Couch
Lamp, Floor
Lamp, Table
Loveseat
Magazine Rack
Mirror(s)
Painting(s)
Piano
Radio
Rug(s)
Sofa, 3-seater
Sofa, Sectional
Stereo Equipment
Table, Coffee or End or Nesting
Table, Drop-leaf or Occasional
Television, Floor Model
Television, Table Model
VCR
Video Game Unit(s) / Games
     
     
     
     
 

KITCHEN

 

Breakfast Table / Chairs
Curtains
Dishes
Flatware
Glassware
Linens
Pictures
Pots / Pans
Small Appliances
Stool
Towels
Utensils / Cutlery
Utility Cabinet
Vegetable Bin
     
     
     
 

PORCH / OUTDOOR EQUIPMENT

 

Barbeque
Bird Bath
Flower Pots
Garden Hose(s)
Glider
Ladder(s)
Lawn Chairs
Lawn Mower / Tractor
Outside Child's Gym
Patio Table
Patio Umbrella
Picnic Bench / Table
Rug(s)
Sand Box
Wheel Barrow
Yard Tools (non-powered)
Yard Tools (powered)
     
     
QTY ARTICLES OWNED VALUE
 

DINING ROOM 

 

Buffet
Cabinet, Corner
Chair(s)
China
China Closet
Curtains / Drapes
Crystal
Linens / Table
Mirror(s)
Painting(s)
Server
Silverware
Table and Extension(s)
Tea Cart
Rug(s)
 

BEDROOMS

 

  Bed including Springs / Mattress:
 { Bed, Bunk (set of 2)
 { Bed, Double
 { Bed, King size
 { Bed, Queen size
 { Bed, Single or Hollywood
 { Bed, Water
Bench, Dresser or Vanity 
Blanket
Bookcase
Bureau / Dresser / Chest
Cedar Chest / Hope Chest
Chair, Boudoir
Chair Straight / Rocker / Glider
Chaise Lounge
Curtains / Drapes
Dresser, Double (Mr. & Mrs.)
Dresser, Single
Dresser, Vanity
Futon(s)
Lamp(s)
Mirror(s)
Night Table(s)
Painting(s)
Pillow(s)
Quilt(s) / Blanket(s)
Sheet Set(s)
Spread(s) / Comforter(s)
Wardrobe / Standing Closet
Rug(s)
 

CLOTHING / SHOES

 

Women's Clothing
Men's Clothing
Children's Clothing / Shoes
Women's Shoes
Purses / Accessories
Men's Shoes
Furs (Must be itemized and detailed)
 

NURSERY

 

Bed, Youth
Chair
Chest
Crib / Bassinet
High Chair
Lamp
Play Pen
Stroller
Table, Childs
Toy Chest
Toys
 

APPLIANCES (LARGE)

 

Air Conditioner, Window
Dehumidifier
Dishwasher
Dryer, Electric / Gas
Freezer
Garbage Compactor
Microwave Oven
Range, Electric / Gas
Refrigerator
Washing Machine
 

PERSONAL ITEMS

 

Eyeglasses / Sunglasses
Perfumes / Colognes
Razor(s)
     
QTY ARTICLES OWNED VALUE
 

MISCELLANEOUS

 

Alarm Clock(s)
Basket, clothes
Bicycle(s)
Books
Cabinet, File
Camera(s) (other than video)
Camera(s) Video
Card Table and Chairs
Carpet(s)
Carriage, Baby
Computer(s)
Computer, Monitor(s)
Computer, Printer(s)
Computer UPS (battery backup)
Desk(s)
Fan(s)
Folding Table
Foot Locker(s)
Golf Bag
Golf Clubs
Hair Dryer
Hamper, clothes
Heater, Gas or Electric
Medications / Cosmetics
Pictures / Framed
Plant Holders
Projector(s)
Records / CDs / Cassettes
Rollaway Bed(s)
Sewing Machine(s)
Shades, Lamp
Sporting Equipment
Suitcase(s)
Telephone Equipment
Tools
Tool Chest / Cabinet
Towels
Toys / Games
Trash Can
Tricycle
Typewriter
Vacuum Cleaner
Video Tapes / DVDs
Wagon, Child's
Water Cooler
Work Bench
QTY

OTHER ITEMS (please list)

VALUE

  SUMMARY  
  Living Room Total
  Kitchen Total
  Porch & Outdoor Total
  Dining Room Total
  Bedrooms Total
  Clothing / Shoes Total
  Nursery Total
  Appliances (large) Total
  Personal Items Total
  Miscellaneous Total
Summary Total Value
 

AUTOMOBILE
 
  Year
  Make
  VIN
  Auto Cash Value
  NON-FACTORY INSTALLED ACCESSORIES MUST BE SEPARATELY LISTED & VALUED BELOW
 
 
 
     
  Auto Total  
  CURRENT CASH VALUE
  SHIPPING CHARGES
  SUMMARY VALUE
  GRAND TOTAL
  SPECIFY CURRENCY
  NOTES

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THIS FORM WILL BE SENT TO THE
MOVER'S EMAIL ADDRESS PROVIDED ABOVE


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