Removal Insurance Proposal Form

REMOVAL INSURANCE PROPOSAL FORM
Complete as fully as possible using tick boxes where applicable. Please use ballpoint pen and sign form returning the original and two copies to the Removal Company, keeping one copy for your
own records.
Name of Customer
Method of Transit
Name :
Address from which goods are to be moved (Origin) :
SEA
AIR
ROAD
Address to which goods are to be sent (Destination)
Will any goods be packed by owner ?
Yes
*
No
Will the goods be stored after packing ?
Yes
*
No
* If yes, please attach a separate valued list
Will the goods be stored prior to delivery to final address ?
* If yes, state how long
Yes
No
* If yes, state how long
MOTOR VEHICLES
All vehicules are subject to a vehicule condition report.
Registration/Serial No
Make/Model
Year
Replacement cost at Destination
The full replacement value of the goods at destination should be insured. If you do not insure for the full replacement value at destination you will only be able to recover a part of your
loss from insurers. Replacement values overseas are frequently greater than in the UK. Attach a separate sheet if required. In respect of goods in long storage customers are strongly
advised to review declared values periodically.
HOUSEHOLD & PERSONAL EFFECTS
(1)
Do not include cash, jewellery, watches, stamps, trinkets or similar valuables. See Clause 8 overleaf. Excluded goods.
(2)
Please include every item that you intend to ship, under the appropriate category. Use additional sheets of paper if necessary.
(3) PLEASE ENSURE THAT ITEMS VALUED INDIVIDUALLY AT MORE THAN £500 ARE LISTED SEPARATELY, or if you have more than one item included under an article description, where
their individual values are not in direct proportion to the quantity declared, you should list each separately noting its replacement value at destination, otherwise you will only be entitled to recover a
proportionate part of the insured value.
FRAGILE ITEMS
Qty / Qté
Qty / Qté
Article
DINING ROOM / SALLE A MANGER
Value
Qty / Qté
Article
FAMILY ROOM/STUDY/ BUREAU
Value
Qty / Qté
Article
LIVING ROOM/SALON
Value
Qty / Qté
Article
Buffet
Books / Livres
Chinese Flowers
Containers
Chair / Chaise
Bookcases /
Bibliothèque
Rugs / Tapis
China / Porcelaine
Rugs / Tapis
Chairs / Chaises
China Cabinet
Vaisselier
Chairs / Chaise
Clock / Horloge
Article
Value
Antiques/Antiquités
Value
Bookcases /
Bibliothèque
Flowers Container
Clocks / Horloge
Clocks / Horloge
Curtains / Rideaux
Curtains / Rideaux
Curtains / Rideaux
Lamp / Lampe
Lamp / Lampe
Desk / Bureau
Mirrors / Miroir
Mirrors / Miroir
Lamp / Lampe
Picture / Tableaux
Pictures / tableaux
Pictures / Tableaux
Sofa / Canapé
Rugs / Tapis
Sofa / Canapé
Center Table
Table / Table
Telephone
TV / VCR
Télé/Magnétoscope
Qty / Qté
Article
Value
Total 1
0
Paris Office : ATLANTIC CORPORATE RELOCATION
Unit Urbaparc - Boulevard de la Libération, 93284 Saint Denis Cedex
Téléphone : +33 (0)1 48 13 33 00 - Télécopie : +33 (0)1 48 13 33 01
R.C. Bobigny B 453 328 544 APE 602 L
Total 2
0
Total 3
0
Total 4
0
REMOVAL INSURANCE PROPOSAL FORM
KITCHEN / CUISINE
Qty / Qté
Article
BATHROOM / SALLE DE BAINS
Value
Qty / Qté
Article
China & Dishes /
Porcelaine &
assiettes
Mirrors / Miroirs
Cooker / Cuisinière
Rugs / Mats / Tapis
Cutlery / Utensils
/Couverts
Refrigerator /
Réfrégérateur
Pots / Pans /
Casseroles Poêles
Freezer /
Congélateur
Electrical
Appliances Appareil
Miscellaneous
kitchenware
Toiletries / affaire
de toilettes
LAUNDRY ROOM / BUANDERIE
Value
Qty / Qté
Article
LINEN / LINGE
Value
Qty / Qté
Iron / Ironing
Board/Table à
repasser + Fer
Vacuum Cleaner
Aspirateur
Washing Machine
Machine à laver
Article
Value
Blankets / Duvets
Pillow
Table Linen
linge de table
Towels / Serviettes
bed linen
Laundy Basket
Towels / Serviettes
Total 7
0
Total 9
0
PHOTOGRAPHIC / MUSICAL
EQUIPMENT
Glassware / Verres
Qty / Qté
Linen / Linge
Article
Value
Camera/Appareil
Photo
Vidéo/Equipment
Microwave oven /
Micro-ondes
Piano
Total 5
0
Total 6
MASTER BEDROOM
Qty / Qté
Article
0
Total 8
BEDROOM 2
Value
Qty / Qté
Beds
Article
0
BEDROOM 3
Value
Qty / Qté
Bed / lit
Article
BEDROOM 4
Value
Qty / Qté
Bed / Lit
Article
Mattress
Mattress
Mattress
Mattress
box spring
box spring
box spring
box spring
Bed base
Bed base
Bed base
Bed base
Bedside Tables
/Table de nuit
Bedside Table /
Table de nuit
Bedside Table/
Table de nuit
Bedside Table
Table de nuit
Carpets / Tapis
Rug / Tapis
Carpets / Rugs
Carpets / Rugs
Chair / Chaise
Chair / Chaise
Chair / Chaise
Chair / Chaise
Chest of Drawers /
Commode
Chest of Drawers
Commode
Chest of Drawers /
Commode
Chest of Drawers
Commode
Curtains / Rideaux
Curtains / Rideaux
Curtains / Rideaux
Curtains / Rideaux
Dressing Table /
Desserte
Dressing Tables
Desserte
Dressing Tables
Desserte
Dressing Tables
Desserte
Lamp / Lampe
Lamp / Lamp
Lamp / Lampe
Lamp / Lampe
Pictures / Mirrors
Tableaux / Miroirs
Wardrobes
Armoire
Pictures / Mirrors
Tableaux / Miroirs
Pictures / Mirrors
Tableaux / Miroirs
Wardrobe
Armoire
Pictures / Mirrors
Tableaux / Miroirs
Tableau Miroir
Value
Bed / Lit
Wardrobe Armoire
Wardrobes Armoire
Total 10
0
Paris Office : ATLANTIC CORPORATE RELOCATION
Unit Urbaparc - Boulevard de la Libération, 93284 Saint Denis Cedex
Téléphone : +33 (0)1 48 13 33 00 - Télécopie : +33 (0)1 48 13 33 01
R.C. Bobigny B 453 328 544 APE 602 L
Total 11
0
Total 12
0
Total 13
0
REMOVAL INSURANCE PROPOSAL FORM
WOMENS CLOTHING/
VETEMENTS FEMME
Qty / Qté
Article
MEN CLOTHING - MENS /
VETEMENTS HOMME
Value
Qty / Qté
Blouses/Chemisiers
Article
CHILDREN CLOTHING/
VETEMENTS ENFANTS
Value
Qty / Qté
Article
Suit / Costume
Shirt / Chemise
Boots / Bottes
Shirt / Chemise
Trouser / Pantalon
Dress / Robe
Trouser / Pantalon
Skirt / Jupe
Handbag /sac à main
Short / Short
Dresses / Robes
Nightwear / Pyjamas
Hats / Chapeau
Sweaters/Sweat
Hosiery / Socks /
Collants
Coat / Jacket /
Manteau / Veste
Coats / Jacket
Jackets / Coats
Shoes / Chaussures
Manteau /veste
Veste / manteaux
Boot / Bottes
Underwear
Sous Vêtements
Scarve / Foulard
Tie / Cravate
Shoes / Boots/
Chaussures/bottes
Shoes / Chaussures
Nightwear /Vêt de nuit
Sweaters/Sweat
SPORT EQUIPMENT /
EQUIPEMENT DE SPORT
Value
Qty / Qté
Article
Value
Golf Clubs
Club Golf
Golf Trolley
Chariot de golf
Gym Equipment
vêtement de sport
Ski Boots/Chaussures
de ski
Socks / Underwear
/sous vêtements +
chaussettes
Sportswear /
vêtement de sport
Shorts / Shorts
Skirts / Jupes
Sportswear /
Vêtements sport
Hats /châpeau
Sweaters / Sweat
Trouser / Pantalon
Underwear / Lingerie
Total 14
0
Total 15
Article
Total 16
ELECTRICAL / HIFI / APPAREILS
ELECTRIQUES
GARDEN / JARDIN/ GARAGE
Qty / Qté
0
Value
Qty / Qté
Article
0
Total 17
PERSONAL ITEMS / Divers
Value
Qty / Qté
Article
Barbecue
Amplifier / Ampli
Child Car Seats/Siège
auto
Bicycles/bicyclette
Cassette Player /
Lecteur K7
Luggage /
Suitcases/sac, valise
Chair & Benche /
Chaise et banc
CD
Prams /
Strollers/Poussette
Drill / Perceuse
Compact Disk Player
Toys/jeux
Garden Tools / Outils
de jardin
Garden Toys /Jeux de
jardin
Computeur /
Ordinateur
Xmas/Noël
Decorations
Value
Computer Software
Other
Hardware/logiciels
autres
Printer / Imprimante
Hose / arrosoir
Ladder / échelle
Lawn Mower / Pelouse
Radio / Radio
Saws / Scie
Records / disques
Swings / Balançoire
Sewing Machine/
Machine à coudre
Tables / Table
Small Appliances
Speakers /
Tapes / K7
Tuner / Radio
DVD Film
TV / TV
Total 18
0
Paris Office : ATLANTIC CORPORATE RELOCATION
Unit Urbaparc - Boulevard de la Libération, 93284 Saint Denis Cedex
Téléphone : +33 (0)1 48 13 33 00 - Télécopie : +33 (0)1 48 13 33 01
R.C. Bobigny B 453 328 544 APE 602 L
Total 19
0
Total 20
0
0
REMOVAL INSURANCE PROPOSAL FORM
1
Total
0
2
Total
0
3
Total
0
4
Total
0
5
Total
0
6
Total
0
7
Total
0
8
Total
0
9
Total
0
10
Total
0
11
Total
0
12
Total
0
13
Total
0
14
Total
0
15
Total
0
16
Total
0
17
Total
0
18
Total
0
19
Total
0
20
Total
SUB TOTAL
Vehicles
0
0
0
Total
0
Paris Office : ATLANTIC CORPORATE RELOCATION
Unit Urbaparc - Boulevard de la Libération, 93284 Saint Denis Cedex
Téléphone : +33 (0)1 48 13 33 00 - Télécopie : +33 (0)1 48 13 33 01
R.C. Bobigny B 453 328 544 APE 602 L
I desire to affect insurance under Atlantic Corporate Relocation ltd Open Marine Policy effected with certain underwriters at Lloyds. I
declare that I have disclosed all material facts and failure to do so could render the insurance void. I declare that the amounts above
stated are the full values of the goods at destination. I have read the conditions of insurance provided and understood that these shall
form the basis of the proposed contract between me and the insurers.
Customers Signature :
Date :
Currency used
(to be specified)
Devise utilisée
(à mentionner)