Insurance application form All-risk musical instrument insurance

Insurance application form
All-risk musical instrument insurance
Applicant:
Name:………………………………………………………………….. Surname:…………………………………………………….
Address :………………………………………………………………………………...………..……..………..………………………
.……………………………….....................................................................................................................................................
Zip/Postal code:…………………………City:………………………………State/Province/Country:………………………….....
Date of birth:…………………………………Phone:………………………………………………………………………………….
E-mail:……………………………………………………………………………………………………………………………………..
Occupation:……………………………………………………………………………………………………………………………….
Musical instrument practice:
Amateur
Student
Professional
Description and value of instruments (please attach justifications)
Description
Value
Choose an option below
A
Just at home (up to € 23,000)
0.65%
B
In all places of France including car thievery 24 hours a day (up to € 23.000)
1.70%*
C
In all places of the world including car thievery 24 hours a day (up to € 23.000)
D
In all places of France without covering car thievery (up to € 23.000)
1.30%
E
In all places of the world without covering car thievery (up to € 23.000)
1.50%
F
In all places of Europe without covering car thievery (from € 23.000 to € 76.000)
0.8%
G
In all places of the world without covering car thievery (from € 23.000 to € 76.000)
2%*
1%
(*) 25% reduction when you insure several instruments belonging to the same family
The annual premium (all taxes included) is equal to the applicable rate multiplied by the value of the instrument, plus €5 of
additional fees. For the options A, B, C, D and E, the minimum annual premium is €60 all taxes included. For the options
F and G, the minimum annual premium is €240 all taxes included.
Place: …………………………………..
Signature :
Date: ………………………
This insurance application form is to be returned to :
Aon France – Défense Ouest - UPI 40/500 – 420 rue d’Estienne d’Orves – 92700 Colombes
Aon France
Société de courtage en assurances et réassurances immatriculée au Registre Unique des Intermédiaires d'Assurances sous le n° 07 001 560
SA au capital de 4 141 334 euros - 414 572 248 RCS Nanterre - Siège social : 420 rue d’Estienne d’Orves - 92700 Colombes
Tél. : 33 (0)1 58 75 75 75 - Fax : 33(0)1 58 75 77 77 - www.aon.fr - N° de TVA intracommunautaire FR 22 414 572 428
GARANTIE FINANCIÈRE ET ASSURANCE DE RESPONSABILITÉ CIVILE PROFESSIONNELLE CONFORMES AUX ARTICLES L 512-7 ET L 512-6 DU CODE DES ASSURANCES