INLAND MARINE MONOLINE

Please FAX completed form to Dave at (201) 652-0721

 

Effective Date: _______________

                              

Policyholder Name(s) : ________________________________________________________

 

                                    ________________________________________________________

 

Telephone Number(s): HOME ____________ CELL ____________ WORK ______________

 

Owner Date of Birth: ______________                    Co-Owner Date of Birth: _______________

 

Owner Social Security #: ___________                    Co-Owner Social Security #: ____________

 

Owner Occupation: ________________                  Co-Owner Occupation: ________________

 

Mailing Address: _____________________________________________________________

 

Location Address (if different): __________________________________________________

 

Telephone Number(s): HOME ____________ CELL ____________ WORK ______________

 

 

(1) Type of Item(s) to Schedule:  Jewelry ___   Fine Art ___   Silverware ___   Cameras ___

 

                                                Musical Instrument ___   Other ___

 

       Description of Item(s) ______________________________________________________

 

                                          _____________________________________________________

 

      Insurable Value: $ _________________________________________________________

 

      Please Check One:  Replacement Cost ___        State Amount ___

 

      Do You Have the Appraisal?  YES ___  NO ___

 

      If YES, is the Appraisal less than 3 years old?  YES ___   NO ___

 

 

(2) Type of Item(s) to Schedule:  Jewelry ___   Fine Art  ___  Silverware ___   Cameras  ___

 

                                                Musical Instrument  ___   Other ___

 

       Description of Item(s) ______________________________________________________

 

                                          _____________________________________________________

 

      Insurable Value: $ _________________________________________________________

 

      Please Check One:  Replacement Cost  ___      State Amount ___

 

      Do You Have the Appraisal?   YES ___  NO  ___

 

      If YES, is the Appraisal less than 3 years old?   YES  ___   NO  ___

 

 

(3) Type of Item(s) to Schedule:  Jewelry ___  Fine Art  ___   Silverware  ___  Cameras  ___

 

                                                Musical Instrument  ___   Other  ___

 

      Description of Item(s) _______________________________________________________

 

                                         ______________________________________________________

 

     Insurable Value: $ __________________________________________________________

 

     Please Check One:  Replacement Cost  ___       State Amount  ___

 

     Do You Have the Appraisal?  YES  ___  NO ___

 

     If YES, is the Appraisal less than 3 years old?   YES  ___  NO  ___

 

 

How did you hear of our Agency?_________________________________________________

 

Please attach any available appraisals.

WE WILL NEED TO ORDER AN INSURANCE SCORE FOR QUOTING.  PLEASE INITIAL WHERE INDICATED FOR PERMISSION TO ORDER SAID DOCUMENT.

 

X ______