New Policy - Valuable Articles

Insured 1 - First Name*

What is your first name? *

Insured 1 - Last Name*

What is your last name? *

What is your preferred phone number?*

What is your preferred phone number? *

Email*

Please enter your email: *

Occupation & Employer*

What is your occupation and employer name? *

Please enter your date of birth.*

Please enter your date of birth.

Spouse*

Will anyone else, such as a spouse, be named on this quote? *

Yes
No

Other Insured's Name*

Please enter their name: *

Other Insured's Occupation & Employer*

Please enter their occupation and employer name: *

Please enter their date of birth. **

Please enter their date of birth. *

Property Address*

Please enter the address where the majority of your valuable articles are kept. *

Street Address Address Line 2 City State ZIP Code

Please select the occupancy of this location. *

Primary home
Secondary home

This field is hidden when viewing the form

Occupancy

Please select the occupancy of this location.

Primary
Secondary
Other

Primary Home Address*

Please enter your primary/current address. *

Street Address Address Line 2 City State ZIP Code

Own or Rent*

Do you own or rent this location? *

Own
Rent

Ownership Structure

Are any of your valuable articles owned by a Trust, LLC or Limited Partnership?

Yes
No

Trust or LLC Name

Please enter the name of the Trust, LLC or Limited Partnership:

Alarm System*

Do you have a monitored alarm system? *

Yes
No

Alarm System Components*

Select the components of your monitored alarm system. *

Heat/Smoke detectors
Burglar motion sensors
Low temperature monitor
Water leak detection
24-hour signal continuity
24-hour video surveillance
Gas leak detection

Valuables Categories*

Please select the categories of valuables articles that you would like an insurance quote for. *

Jewelry
Fine Art
Wine
Musical Instruments
Other

Jewelry Collection

Please fill in the values for your jewelry collection below.

Number of Pieces in Collection	Collection Value (Approx.)	Highest Value Piece ($ value)

Jewelry Details

Select all that apply to your jewelry collection.

Have recent appraisals (2 years or newer)
Some/all pieces in-vault at a bank
Permanently installed in-home safe

Appraisal upload

Use this field to upload appraisals and/or a jewelry schedule.

Drop files here or

Max. file size: 128 MB.

Fine Art Collection

Please fill in the values for your art collection below.

Number of Works in Collection	Collection Value (Approx.)	Highest Value Piece ($ value)

Wine Collection

Please fill in the values for your wine collection below.

Number of Bottles in Collection	Collection Value (Approx.)	Highest Value Piece ($ value)

Musical Instruments

Please fill in the values for your musical instruments collection below.

Collection Value (Approx.)	Highest Value Piece ($ value)

Collectibles (Comics, Stamps, Figurines, etc...)

Please fill in the values for your collectibles (Comics, Stamps, Figurines, etc...) collection below.

Collection Value (Approx.)	Highest Value Piece ($ value)

Documents and Comments

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, jewelry/fine art schedules, etc...)

Drop files here or

Accepted file types: jpg, gif, tiff, png, pdf, Max. file size: 128 MB, Max. files: 5.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Please share what you typed into Google.

Please share how you heard about us.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

I agree

Valuable Articles Insurance Form

Documents and Comments

Cecilia Rivera

RiskRevu^TM Newsletter

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Valuable Articles Insurance Form

Documents and Comments

Cecilia Rivera

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter