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30 Windsormere Way
Suite 200
Oviedo, FL   32765
 


WORLD WIDE TRANSPORTATION INSURANCE SPECIALISTS


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:
 

Name of Mover:

Mover Email Address:

Mode of Shipment:
Land Sea Air

Origin:

Destination:

Deductible Amount: 

Pick Up Date:

 

ARTICLES OWNED

QTY

LIVING ROOM

VALUE

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
QTY

DINING ROOM 

VALUE

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)
QTY

CLOTHING / SHOES

 VALUE

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

BEDROOMS

VALUE

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)
QTY

KITCHEN

VALUE

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

APPLIANCES (LARGE)

VALUE

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

ARTICLES OWNED

QTY

NURSERY

VALUE

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

PORCH / OUTDOOR EQUIPMENT

VALUE

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

PERSONAL ITEMS

VALUE

Eyeglasses / Sunglasses
Perfumes / Colognes
Razor(s)
QTY

MISCELLANEOUS

VALUE

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