UNIRISC
APPLICATION FORM FOR ALL RISK 
REPLACEMENT INSURANCE COVERAGE
MOVER:       CERTIFICATE#:
   
    THIS IS NOT A CERTIFICATE OF INSURANCE
INSURED:     ORIGIN CITY, COUNTRY:     DATE PACKED:  
               
DESTINATION: (COMPLETE ADDRESS)           MOVING BY:  
           
SEA                  AIR
 
SCHEDULE OF GOODS TO BE INSURED
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 a replacement cost less depreciation.  Both options are subject to 100% co-insurance.
Items grouped together are considered to be of equal value.  You may attach additional pages, if necessary to properly detail your shipment.
A. LIVING ROOM     E. LINEN/CLOTHING     H. BEDROOM NO. 1 (Master):     L. MISCELLANEOUS    
Article No. Replace.  Article No. Replace.  Article No. Replace.  Article No. Replace. 
  Item Cost   Item Cost   Item Cost   Item Cost
Sofa(s)     Coat(s)/Jackets     Chair(s)     Typewriter(s)    
Chair(s) - Ottomans     Suit(s)     Bed (s)     Clocks    
Lamp(s) & Shade(s)     Dresses     Night Table(s)     Bric-a-brac    
Table(s)     Sport Coats (s)     Dress. Table/Vanity     Baskets, Plant Holders    
Radio     Slack (s)     Bench     Toy & Games    
Stereo Equipment     Sweater(s)     Chest & Drawers     Food    
TV(s)     Blouse(s)     Mirror(s)     Liquor/Wine    
Rug(s) & Carpet(s)     Skirts(s)     Rug(s)     Sewing Machine    
Desk     Shirts(s)     Lamp(s)     Sewing Supplies    
Curtains & Drapes     Sleepwear     Curtains & Drapes     Sports Equip.    
Piano or Other Musical     Shoes     Bookcase(s)     Books    
Video Recorder     Boots     Desk(s)     Fireplace Equipment    
Bookcase/Room Divider     Hosiery/Socks     Armoire/Wardrobe     Bicycles    
B. Dining Room     Ties/Scarves     Other     Albums    
Table(s)     Underwear     I. BEDROOM NO. 2:     Audio Tapes    
Chair(s)      Lingeries     Chair(s)     Video Tapes    
China Closet     Sportswear     Bed (s)     Video Camera    
Buffet     Purses/Handbags     Night Table(s)     Computer    
Serving Table/Tea Cart     Hat/Gloves     Dress. Table/Vanity     Computer Acces.    
Lamps & Chandeliers     Sheet(s)     Chest & Drawers     M. Other (Specify)    
Rug(s) & Carpet(s)     Pillow Cases     Mirror(s)          
Curtains & Drapes     Spread (s)     Rug(s)          
Mirrors     Quilt (s)     Lamp(s)          
Table Linens/ Acessories     Blanket (s)      Curtains & Drapes          
C. KITCHEN     Comforters     Bookcase(s)          
Cleaning Supplies     F. BASEMENT & GARAGE     Desk(s)          
Dinette Set     (Excluding Car)     Armoire/Wardrobe     COLUMN SUB-TOTAL   0
Elec. Appliances     Workbench     J. BEDROOM NO. 3:                   TOTAL HOUSEHOLD GOODS
Cabinets/Tables     Tools: Hand     Chair(s)        
Kitchen Linens & Curtains     Tools: Power     Bed (s)          $                -  
Dishwasher     Vacuum Cleaner     Night Table(s)     Automobile / Motorcycle: Written on Actual Cash Value     
Oven/Range     Lawn Mower     Dress. Table/Vanity     Yr./Make:  
Microwave     Garden Tools     Chest & Drawers     Serial No.:  
Dishes     Furniture (Patio)     Mirror(s)          
Utensils/Cutlery     Luggage/Trunks     Rug(s)     Non-Factory Installed Auto Accessories 
Pots and Pans     Washing Machine     Lamp(s)     Must be Seperately Listed & Valued
Bowls, Trays, Etc     Ironer/Ironing Board     Curtains & Drapes        
Refrigerator/Freezer     Clothes Dryer     Bookcase(s)        
Trash/ Garbage Cans     Other     Desk(s)        
D. CHINA & GLASSWARE     G. BATHROOMS     Armoire/Wardrobe          
China     Rugs, Toilet Covers     K. DEN/FAMILY ROOM                   TOTAL AUTOMOBILE  
Glassware     Toilet Articles/Medical Supplies     Chair(s)          $                -  
Crystal     Towels, etc.     Curtains & Drapes        
      Clothes Hamper     Sofa          
SILVER     Trash Can     Table(s)                               GRAND TOTAL
      Cabinets, Shelves, Mirrors     Lamp(s)          
      Razors, Hair Dryers     Rug(s) & Carpeting        $                -  
      Make-up     Desk(s)          
      Perfume     Bookcase(s)/Wall Unit(s)          
COLUMN SUB-TOTAL  $        -   COLUMN SUB-TOTAL  $        -   COLUMN SUB-TOTAL  $        -  
PLEASE INSURE MY SHIPMENT FOR _________________________ WHICH REPRESENTS COST AT DESTINATION OF EVERYTHING IN MY SHIPMENT.     
_____________________________________ ______________
SIGNATURE DATE
Please retain a copy for your files