Proposal for Shipment

Household Goods and

Personal Effects

INSURANCE IS THE SUBJECT MATTER OF SOLICITATION: The liability of AXA Insurance (Gulf) B.S.C. (c) does not commence until the Proposal
has been accepted and the Premium paid or agreed to be paid. AXA Insurance (Gulf) B.S.C. (c) reserves the right to ask for special terms or
decline the Proposal. Please refer to the Policy for full terms, conditions & exclusions. A specimen copy of this Policy is available from any
AXA branch office in the Gulf or on our website www.axa-gulf.com.

Proposer:
Address at Origin:
Address at Destination:
Shipped by (Please Tick):

Sea

Air

Professional

Packing (Please Tick):

Over Land

Self (Restricted cover only)

Approx. commencement date of transit:

No of packages:

Packing Companys Name:

Option for insurance (Please tick):

Valued Inventory Basis

Bulk Basis

Valued Inventory Basis:

All items should be insured for present day market value at destination. Failure to do so will result in valuation clause being applied.
All items being shipped must be declared for insurance.
Describe each Item and give Individual values. Please give details of each set.
Please list separately any items exceeding US$ 1,000/=
No.

ARTICLES

No. Items Replacement cost

No.

ARTICLES

A
1
2
3
4
5
6
7
8
9
10
11
12
13
14

LIVING ROOM
Sofas
Chairs
Lamps & Shades
Tables
Radios
TVs
Rugs & Carpets
Curtains
Piano & Musical Instruments
Bookcase/Wall Unit
Cupboards
Hi-Fi system/Home Theatre
Pictures & Paintings
Video Recorder/DVD

5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

Kitchen Linen
Dishwasher
Oven/Cooker
Microwave
Crockery
Utensils/Cutlery
Pots & Pans
Bowls, Trays Etc
Plastic/Tupperware
Food Processor
Refrigerator
Freezer
Vacuum Cleaner
Washing Machine
Dryer

B
1
2
3
4
5
6
7
8
9
10
11

DINING ROOM
Tables
Chairs
Cupboards
Sideboard
Lamps & Chandeliers
Rugs & Carpets
Curtains
Mirrors
Table Linen
Pictures & Paintings
Desk

C
1
2
3
4
5
6
7
8
9
10

FAMILY ROOM
Chairs
Curtains
Sofas
Tables
Lamps/Shades
Rugs & Carpets
Desk
Bookcases
Pictures & Paintings
Cupboards

G SILVERWARE/BRASSWARE
1
2
3
4

D
1
2
3
4

KITCHEN
Tables
Chairs
Electrical Appliances
Cabinets

I SPORTS EQUIPMENT
1
2
3
4

E CHINAWARE/PORCELAIN
1
2
3
4
F CRYSTAL/GLASSWARE
1
2
3
4

H ANTIQUES/ WORKS OF ART

1
2
3
4

No. Items Replacement cost

No.

ARTICLES

J
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

LINEN/CLOTHING
Coats/Jackets
Suits
Dresses
Trousers
Sweaters
Blouses
Skirts
Sleepwear
Shirts
Footwear
Hosiery/Socks
Ties/Scarves
Underwear
Lingerie
Sportswear
Sheets/Linen

K
1
2
3
4
5
6
7
8
9
10
11
12

BEDROOM (MAIN)
Beds
Chairs
Tables
Wardrobes
Dressing Table
Chest of Drawers
Mirrors
Rugs
Lamps
Curtains
Bookcases
Pictures/Paintings

L
1
2
3
4
5
6
7
8
9
10
11
12

BEDROOM(S) OTHERS
Beds
Chairs
Tables
Wardrobes
Dressing Table
Chest of Drawers
Mirrors
Rugs
Lamps
Curtains
Bookcases
Pictures/Paintings

M
1
2
3
4

BATHROOM
Rugs, Toilet Covers
Toiletries
Medical Supplies
Towels

No. Items Replacement cost

No.

ARTICLES

5
6
7
8
9
10

Laundry Basket
Perfume/Aftershave
Cabinet/Shelves
Mirrors
Razors
Hair Dryers

N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

MISCELLANEOUS
Clocks
Telephone/Fax
Plant Holders
Toys & Games
Food (Non-perishable)
Computer
Computer Printer
Computer Accessories
Sewing Machine
Video Cameras
Cameras/Lens
Pictures/Paintings
Bicycles
Books
Audio Tapes
CDs
Video Tapes/DVDs
Garden Equipment
Garden Furniture
Suitcases/Trunks
Tools

No. Items Replacement cost

O ANY OTHER ITEMS

1
2
3
4
5
6
7
8
TOTAL (Insured Value) Please state currency

Please Tick cover required:

Full Conditions (professionally packed goods only)

Extensions For Full Conditions Only:

(Please tick if cover required)

Pair & Set

Mould & Mildew

Restricted Conditions

Mechanical Derangement and/or Electrical and/or Electronic

Bulk Basis: USD 2,750 per cubic meter subject to a minimum volume of 5 CBM. Any Single item over USD 1,000 to declared separately in the
itemized list provided above & total value to be added to bulk value arrived at.
(A) Value in cubic meters:

(B) Bulk Insured Value ( ____ CBM x USD 2,750): 0.00

(C) High Value items as per

list provided above (over USD 1,000/per item):

TOTAL (Insured Value) (in USD) (B+C):

0.00

All material facts must be disclosed, failure to do so could invalidate the policy. A material fact is one which would be likely to influence
an insurer in the assessment and acceptance of the proposal. If in any doubt as to whether a fact is material then it should be disclosed
here.
Declaration: I declare that the details herein are correct according to the best of my knowledge and belief and agree that the particulars and
statements given shall form the basis of contract between us and shall be incorporated in the Policy, if issued. It is agreed that the Insurer
is liable in accordance with the terms of the Policy only and that the Insured will not lodge any other claims of whatever nature. I shall provide any additional information that maybe required by AXA Insurance (Gulf) B.S.C (c). I confirm that I have read, understand and accept the
terms and conditions stated in the booklet. I am aware that a minimum excess of AED.500 or equivalent applies to this insurance cover.
Date:

Proposer Signature:
UAE: 800 48 45, Bahrain: 800 010 60, Oman: 800 70 292, Qatar: 800 29 21