certificate of insurance/certificat d`assurance

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certificate of insurance/certificat d`assurance
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CERTIFICATE OF INSURANCE/CERTIFICAT D'ASSURANCE
For marine insurance underwritten at Lloyd's
of London, covering personal and household
effects and private passenger automobiles.
Certificate No./№ du Certificat
Pour l'assurance marine souscrite à Lloyd's
of London, couvrant des effets personnels
et de ménage et des autos de passager privées.
Insured/Assuré(e):
Pack Date/Date d’Emballage:
Moving From/Déménage de:
Moving To/Déménage à:
Origin Agent/Agent d’Origine:
Destination Agent/Agent de Destination:
Mover’s Ref. #/№ Réf. du Déménageur:
Shipment Weight/Poids de Cargaison:
Account/Compte:
Insured Value of Household Goods/Valeur Assurée d'Articles de Ménage
$
Insured Value of Automobile Valeur Assurée d'Auto
(include accessories)
(inclut des accessoires)
$
Year/Année
Make/Marque
Model/Modèle
Insurance, Packing & Shipping Charges/Frais d’Assurance, d’Emballage & d’Expédition
$
TOTAL INSURED VALUE/VALEUR ASSURÉE TOTALE
$
Shipment is moving via/Cargaison se déplace via:
Surface
$ USD
Air
Coverage Requested/Couverture Demandée
Standard Coverage /
Couverture Standard
Enhanced Coverage
(includes pairs/sets, mechanical malfunction, mold/mildew)
Couverture Rehaussée
Total Loss Coverage Only /
Couverture Perte Totale Seulement
(inclut paires/séries, dérangement mécanique, moule/moisissure)
A valued inventory is attached based upon the replacement cost at destination /
Inventaire valorisé est attaché basé sur le coût de remplacement à la destination
No valued inventory has been completed. The insurance value is based upon /
Inventaire valorisé n’a pas été complété. La valeur d’assurance est basée sur
Actual Cash Value /
Valeur Réelle
Valuation of $__________ per pound
Valuation de $__________ par livre
Deductible Amount of $___________ to be taken off claim payment
Déductible au montant de $___________ sera enlevé de paiement de réclamation
Deductible Amount of $___________ to be billed to__________________________________________
Déductible au montant de $___________ sera facturé à ______________________________________
Client Signature/Signature de Client _____________________________________ Date Issued/Date Publiée __________________
AGENT COPY/COPIE D’AGENT
CERTIFICATE OF INSURANCE/CERTIFICAT D'ASSURANCE
For marine insurance underwritten at Lloyd's
of London, covering personal and household
effects and private passenger automobiles.
Certificate No./№ du Certificat
Pour l'assurance marine souscrite à Lloyd's
of London, couvrant des effets personnels
et de ménage et des autos de passager privées.
Insured/Assuré(e):
Pack Date/Date d’Emballage:
Moving From/Déménage de:
Moving To/Déménage à:
Origin Agent/Agent d’Origine:
Destination Agent/Agent de Destination:
Mover’s Ref. #/№ Réf. du Déménageur:
Shipment Weight/Poids de Cargaison:
Account/Compte:
Insured Value of Household Goods/Valeur Assurée d'Articles de Ménage
$
Insured Value of Automobile Valeur Assurée d'Auto
(include accessories)
(inclut des accessoires)
$
Year/Année
Make/Marque
Model/Modèle
Insurance, Packing & Shipping Charges/Frais d’Assurance, d’Emballage & d’Expédition
$
TOTAL INSURED VALUE/VALEUR ASSURÉE TOTALE
$
Shipment is moving via/Cargaison se déplace via:
Surface
$ USD
Air
Coverage Requested/Couverture Demandée
Standard Coverage /
Couverture Standard
Enhanced Coverage
(includes pairs/sets, mechanical malfunction, mold/mildew)
Couverture Rehaussée
Total Loss Coverage Only /
Couverture Perte Totale Seulement
(inclut paires/séries, dérangement mécanique, moule/moisissure)
A valued inventory is attached based upon the replacement cost at destination /
Inventaire valorisé est attaché basé sur le coût de remplacement à la destination
No valued inventory has been completed. The insurance value is based upon /
Inventaire valorisé n’a pas été complété. La valeur d’assurance est basée sur
Actual Cash Value /
Valeur Réelle
Valuation of $__________ per pound
Valuation de $__________ par livre
Deductible Amount of $___________ to be taken off claim payment
Déductible au montant de $___________ sera enlevé de paiement de réclamation
Deductible Amount of $___________ to be billed to__________________________________________
Déductible au montant de $___________ sera facturé à ______________________________________
Client Signature/Signature de Client _____________________________________ Date Issued/Date Publiée __________________
CUSTOMER COPY/COPIE DE CLIENT
CAUTION: THIS IS YOUR INSURANCE CONTRACT-BE SURE YOU READ
AND UNDERSTAND IT AND COMPLY WITH ALL TERMS AND CONDITIONS
PROPERTY COVERED
Personal and Household Effects and Private Passenger Automobiles as specified in declarations on reverse side.
COVERAGE
Marine "All RISKS" of physical loss or damage to covered property from whatsoever cause arising except as excluded below, including general average and
salvage charges.
This Policy does NOT cover:
(a) Consignments when the value of china, glass, earthenware, marble and the like represents more than ten percent (10%) of the total value of the shipment.
This percentage may be increased to a maximum of twenty percent (20%) subject to the payment of the appropriate additional premium and an itemized
list of articles being specifically declared at the time of shipment.
(b) Breakage of china, glass and other brittle or fragile articles unless directly caused by fire, stranding, sinking or collision of the vessel or collision or overturn
of transporting land conveyance. THE FOREGOING DOES NOTAPPLY IF SUCH ARTICLES WERE PROFESSIONALLY PACKAGED.
(c) Scratching, denting, or marring of automobiles unless the shipper and the owner of the automobile both agree and sign a "Certificate of Condition" or
similar document stating the condition of the automobile at origin, noting all defects, if any.
(d) Non-factory installed accessories or removable items on automobiles unless specifically declared and valued for insurance. Miscellaneous household
items shipped in automobiles are not covered. These must be packed, shipped and insured separately.
(e) Loss or damage caused by normal wear and tear, mechanical or electrical derangement, wrinkling of clothing, vermin, moths, insects or inherent vice.
(f) Change in climatic condition, including susceptibility to damage because of atmospheric conditions such as extreme fluctuations in temperature or
humidity.
(9) Loss of or damage to cash, currency, bank notes, stocks, bonds, postage stamps or any negotiable instrument.
(h) Loss of or damage to personal papers of any kind, including but not limited to dissertations, tax returns, medical and employment records, jewelry, furs,
coin, stamp or other collections of any kind unless specifically declared and valued for insurance.
(i) Depreciation in market or appraised value of any item when such depreciation arises as the result of a peril insured hereunder, Underwriter's liability
hereon is governed by the "Repair or Replacement Clause" found in this policy.
(j) Data contained on diskettes, cassettes, video tapes, etc. Claim is limited to cost of hardware only.
(k) NUCLEAR EXCLUSION CLAUSE: Underwriters shall not be liable for loss by nuclear reaction or nuclear radiation or radioactive contamination, all
whether controlled or uncontrolled, and whether such loss be direct or indirect, proximate or remote, or be in whole or in part caused by, contributed to, or
aggravated by the peril(s) insured hereunder, however, subject to the foregoing and to all the provisions expressed herein, direct loss by fire resulting from
nuclear reaction or nuclear radiation or radioactive contamination is hereby insured.
(I) WAR RISK EXCLUSION CLAUSE: Not withstanding anything to the contrary herein contained, THE FOLLOWING CLAUSE DOES NOT APPLY WHILE
THE INSURED INTEREST IS WATER OR AIRBORNE. This Policy does not cover loss or damage, if any act or event, out of or in the course of which such
loss or damage arises, constitutes or is a part of or is committed or happens whether directly or indirectly by reasons of, or in connection with war, invasion,
act of foreign enemy, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, military or unsurped
power, martial law, or the act of any lawfully constituted Authority, and in any claim, and in any action, suit or other proceedings to enforce a claim for loss or
damage under this Policy, the burden of proving that the loss or damage does not fall within this clause shall be upon the insured.
(m) Directions or damage to automobile while being driven under its own power except while on premises or port and while being driven in the U.S. by an
authorized driver who is an employee of the freight forwarder.
(n) Shipments forwarded on deck at shippers request.
(0) MILLENNIUM EXCLUSION: This contract excludes loss, damage, liability or expense arising from or in any way connected, whether directly or
indirectly, with:
1.The actual or anticipated failure or inability of any computer or electronic device or component or system or embedded programming or software,
whether or not belonging to or in the possession of the direct assured:
(A) Correctly and unambiguously to assign any date to the correct day, week, year or century;
(B) Correctly to recognize or compute any date which is or is intended to be beyond December 1998;
(C)To continue to operate as it would have done had its current date, the true date and any other date relevant to any function being carried out by it
been prior to 1 January 1999..
2. The use of any arbitrary, ambiguous or incompletely defined date in any data, software, or embedded programming.
3. Any measure taken with the intention of averting or minimizing any of the above.
In the event of direct loss of or damage to computer equipment, electronic devices, components, systems, embedded programming or software insured under
this contract which is not Year 2000 compliant, liability shall be limited to Actual Cash Value giving due consideration for obsolescence.
CONDITIONS
1. 100% Coinsurance Clause: The Insured shall maintain insurance on the entire shipment and failing to do so, the insured shall to the extent of such deficit,
bear his or their proportion of any loss. Furthermore, in every event of loss or damage, this insurance shall not attach or cover for more than the amount
specified opposite each category of goods listed on the reverse side or as scheduled elsewhere, and in no instance shall coverage attach for an amount
greater than the actual market value or replacement cost of any item.
2. Deductible Clause: Each claim for loss or damage shall be adjusted separately and from the amount of each such adjusted claim or applicable limit
of liability, whichever is less, THE SUM as shown on the reverse side shall be deducted. This deductible applies separately to each claim placed
against household goods and automobiles.
3. Pairs & Sets Clause: Where any insured item consists of articles in a pair or set, this Certificate shall not pay more than the value of any particular
part or parts which may be lost or damaged, without reference to any special value which such article or articles may have as part of such pair or set,
nor more than a proportionate part of the insured value of the pair or set.
4. Repair or Replacement Clause: Underwriters retain the right to inspect and or appraise any item prior to its repair or disposal. Underwriters shall be
entitled at their sole option, to repair or replace with like kind and quality, any article lost or damage (whether wholly or in part) or to pay cash
therefore not exceeding in any event the sum insured, or the actual market value or replacement cost of any item, whichever is less. Underwriters
retain the right to request substantiation of the values listed on a valued inventory. In no instance can payment exceed the true value of an item.
5. Salvage Clause: Where replacement or total loss payment of a damaged articles(s) is made by Underwriters, they, at their sole option, have the right
to salvage of the damaged articles.
6. Prima Facie Evidence Clause: The origin and/or destination packing inventory as prepared by the mover and signed by the Insured and mover shall
be assumed as Prima Facie Evidence of delivery of the shipment in good order with the exception of any notations made by the Insured at the time
of delivery, noting missing/damage cartons. .
7. Claims Notification: In the event of loss, damage or non-delivery which may give rise to a claim under this certificate, immediate notice must be given
in writing to UNIRISC at the address shown on this certificate. Failure to give notice within 45 days after delivery of the shipment will void coverage
under this certificate. Further it is understood and warranted that presentation of claim after notice will be in a timely fashion not to exceed 90 days
from the time of such notice.
8. Misrepresentation and Fraud: This entire certification shall be void if, whether before or after a loss, the Insured has concealed or misrepresented any
material fact or circumstances concerning this insurance or the subject thereof, or the interest of the Insured therein, or in case of any fraud or false
swearing by the Insured relating thereto.
9. Territorial Conditions:
a. Household Goods: Coverage is to apply from such time as packing by an authorized mover commences at origin residence and continues during
the normal course of transit until unpacking by an authorized mover is completed at the destination residence, provided that all other terms and
conditions of this coverage are met. Coverage will only attach to the goods while they are in the care, custody, and control of an authorized mover
or its agent.
b. Automobiles: Coverage is to apply from the time that the automobile is given into the custody of the freight forwarder or steamship company and
continues until the automobile is delivered to point of final destination provided it is not operated on public or private roads under its own power
from time of discharge from the vessel until arrival at such final destination. This provision does not apply to transportation between conveyances
provided such transportation does not exceed ten (10) statute miles. Further coverage does not apply for any period exceeding 72 hours at
destination ocean port should this be the point of final destination.
c. Storage Coverage Extensions:Storage is provided in the basic premium for 60 days at origin and 60 days at destination, providing that the
tproperty is stored in an enclosed protected warehouse under the care, custody and control of the mover. Mini and/or self storage facilities
are excluded. For Sections I & II coverage many be extended for additional periods of storage subject to prior notice and payment of additional
premium to UNIRISC. Special notice shall be in writing and made upon the appropriate application provided.
10. Other Insurance: This insurance does not cover to the extent of any other insurance, whether prior or subsequent hereto in date and by whomsoever
effected directly or indirectly covering the same property, and the Underwriters shall be liable for loss or damage only for the excess value beyond
the amount due from such other insurance.
11. Subrogation Clause: The Underwriters shall be subrogated to the extent of their payment for losses insured hereunder and to the Insured's rights to
recovery against any person or organization; excepting the origin and destination freight forwarders and packers who performed pickup, packing,
delivery and unpacking services in connection with the movement of the shipment. All provisions of this clause not withstanding, it is hereby
warranted that the Insured shall take all necessary actions to protect Underwriter's rights of subrogation against possibly culpable parties. Failure to
take such action, causing prejudice to Underwriters' rights of subrogation, may result in a reduction or denial of any claim made under this insurance.
12. High Value Articles: Any item with an individual value of 2% or more of the total value of your shipment, is defined as "High Value Article" and must be
specifically declared and valued at the time of shipment.
13. Premium Payment: Where the named Insured herein has not paid premium directly to UNIRISC, any party receiving premium from the herein named
Insured is constructed as the Insured's agent for payment of said premium to UNIRISC and failure of UNIRISC to receive such premium will void any
coverage under the Certificate.
INTERNATIONAL CLAIM REPORTING PROCEDURE
TIME LIMITATIONS ON FILING A CLAIM
1. YOU MUST NOTIFY UNIRISC OF YOUR INTENT TO FILE CLAIM WITHIN 45 DAYS OF DELIVERY TO YOUR RESIDENCE.
2. COMPLETED CLAIM FORM AND ATTACHED DOCUMENTS MUST BE FORWARDED WITHIN 90 DAYS FROM DATE OF
NOTIFICATION OF INTENT TO FILE CLAIM.
IMPORTANT — IN THE EVENT OF LOSS AND/OR DAMAGE BELIEVED COVERED BY THIS CERTIFICATE INSURED
MUST IMMEDIATELY:
1. Report loss to the Agent of the Moving Company. A survey may be performed by any local reputable survey agent or agent of Lloyd's of
London. However, surveys are NOT authorized if loss or damage is less than $1,000.00 unless there are unusual circumstances.
2. Complete the Claim Form found following your insurance certificate. A Claim Form MUST be submitted with ALL claims. Incomplete
Claim Forms will NOT be processed and will be returned for all questions to be answered.
3. Write a letter directly to the air or ocean carrier (NOT the Moving company) who handled your shipment stating that there has been
damage to the shipment. Attach a copy of this letter to your Claim Form.
4. Obtain Estimates for Repair of damages and attach to the Claim Form. Any items which are claimed as total loss must be substantiated.
5. Attach a copy of the Ocean or Air Way Bill of Lading to the Claim Form.
6. Attach a copy of the Destination Inventory with exceptions noted.
7. Attach a copy of your insurance certificate.
8. In the event of loss or damage to an individual "High Value" article, Underwriters, or their representatives, have the right to request the
Insured to verify the value and furnish proof of ownership prior to payment.
9. Air Mail your Claim Form with attached documents directly to:
UNIRISC
9040 Leslie Street
Suite 215
Richmond Hill, ON L48 3M4
Telephone (905) 764-7272
FAX (905) 764-7273
[email protected]
NOTE: In the event you wish Underwriters to assign a loss adjuster directly, or require assistance in submitting your claim,
notify UNIRISC immediately:
CLIENT NUMBER/NUMÉRO DU CLIENT
1
WORLDWIDE CARGO CLAIM FORM
DEMANDE DE DÉDOMMAGEMENT
EMPLOYER/DIVISION (IF APPLICABLE) / EMPLOYEUR/DIVISION (LE CAS ÉCHÉANT)
2
™
CLAIMANT'S NAME/ NOM DU DEMANDEUR
3
SHIPMENT ORIGIN ADDRESS/ANCIENNE ADRESSE
7
TAG NO
ÉTIQ. No
CLAIMANT'S MAILING ADDRESS/POSTAL CODE
ADRESSE POSTALE DU DEMANDEUR/CODE POSTALE
CARRIER REF. NO.
No DE RÉF. DU TRANSPORTEUR
4
5
DATE OF PICK-UP
DATE DE RAMASSAGE
DELIVERY ADDRESS (IF OTHER THAN #4)
ADRESSE DE LIVRAISON (SI DIFFÉRENTE DU No 4)
8
9
DESCRIPTION OF ARTICLE
DESCRIPTION DE L'ARTICLE
NAME OF MOVING COMPANY / NOM DE LA COMPAGNIE DE DÉMÉNAGEMENT
6
DATE OF DELIVERY
DATE DE LIVAISON
À L'USAGE DE L'ÉVALUATEUR SEULEMENT
No DE DEMANDE UNIRISC
10
REPLACE
DATE OF
COST
PURCHASE
COûT DE
DATE
D'ACHAT REMPLAC.
NATURE AND EXTENT OF DAMAGE
NATURE ET AMPLEUR DES DOMMAGES
I am the owner of the property described. I did not cause or contribute to the damage set forth herein.
All statements made in this statement of claim and any attached documents are true and correct to the best of my knowledge and belief, and constitues my complete
and entire claim. No material information has been withheld.
I hereby assign and transfer to UNIRISC any and all claims and recoveries arising out of the shipment of my household goods.
AMOUNT
CLAIMED
MONTANT
RÉCLAMÉ
The actual cash value of my shipment was
(
$
APPROX. WEIGHT
POIDS APPROX.
AMOUNT
ALLOWED
MONTANT
ACCORDÉ
CARRIER
LIABILITY
RESP. DU
TRANSP.
EXCESS
RESPONSIBILITY
EXCES DE
RESPONSABILITÉ
TOTALS
TOTAUX
Attach a copy of the bill of lading and the inventory.
Please mail to:
Veuillez joindre une copie du connaissement et
l'inventaire, et les envoyer à:
Je suis propriétaire des articles décrits ci-dessus. Je n'ai ni causé ni contribué aux dommages cités dans la présente.
Les éléments inclus dans la présente demande de dédommagement sont, pour autant que je sache, exacts, et constituent mon entière demande de
dédommagement. Aucune information pertinente n'a été retenue.
Je cède et transfère par la présente à Unirisc toute demande de dédommagement et obtention résultant de l'envoi de mes articles ménagers.
La valeur réelle de mes biens est de
FOR ADJUSTERS USE
ONLY UNIRISC CLAIM NO.
)
HOME PHONE NO./No DE TÉL.(DOMICILE)
(
CLAIMANT'S SIGNATURE/SIGNATURE DU DEMANDEUR
DATE
)
o
BUS. PHONE NO./N DE TÉL. (BUREAU)
9040 Leslie Street, Suite 215
Richmond Hill, Ontario L4B 3M4 Fax: (905) 764-7273