Collectors Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Address Line 1
Address Line 2
City
County
Postcode
Phone Number
*
-
Area Code
Phone Number
Occupation
*
Date of Birth
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Is the collection kept at the above address?
*
Yes
No
Please state address where it is kept:
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Cover Required
Total Sum at the above address (£)
*
Total Sum in Bank Vault (Only) (£)
*
Total Sum Normally Bank (Bank vault, with a limit of 30 days out of the vault in a year) (£)
*
Total Sum Anywhere Country of Residence (if not UK) (£)
*
Total Sum Worldwide Cover
*
Value of top item (£)
*
An individual stamp, block, pane, cover or postal history item. Having a market value of £2,500 or more will only be covered under this policy if seperately listed on the Schedule of Specified Items.
List items worth £2,500 or more (Catalogue No. Mint/unused/used condition est.value)
*
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Collection Value Details
Has the collection been professionally valued?
*
Yes
No
By whom was the last evaluation conducted?
Date of last evaluation
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
On what basis was the value of the collection determined?
Is a complete record of collection maintained?
*
Yes
No
Please state how exact amount of loss would be calculated?
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Location Details - Is the address at which the collection is kept:
Self-contained and exclusively under your sole control?
*
Yes
No
Built of brick, stone or concrete or with walls of other incombustible or fire resistive material?
*
Yes
No
Are all external doors fitted with either a multi-point locking system or a 5-lever mortice deadlock?
*
Yes
No
I'm not sure
Please give details of makes and types of locks fitted:
Are all accessible windows fitted with window locks having removable keys?
*
Yes
No
Do you have a burglar alarm?
*
Yes
No
Is the collection kept in a safe, locked cabinet or fire-proof cabinet?
*
Yes
No
Please provide details
Please state maximum amount NOT kept in safe, if applicable (£)
Please provide details of where it is stored
Do you have any other forms of protection, i.e CCTV, Electronic Gates, Smoke Alarms etc.?
*
Yes
No
What forms of protection do you have installed?
*
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Insurance History
Have you sustained a loss of any of the risks now to be insured against?
*
Yes
No
Is the collection presently insured?
*
Yes
No
Please state name of insurer
Have you ever had your insurance cancelled?
*
Yes
No
Have you ever had your renewal refused?
*
Yes
No
Have you ever had your premium increased?
*
Yes
No
Has your insurance ever been revised with addition Terms & Increased rates?
*
Yes
No
On what date is this insurance to commence?
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Declaration
*
To the best of my knowledge and belief the sums insured above represent the full value of the property to be insured. The information provided in connection with this proposal application, whether in my hand or not, is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation will entitle the insurers to void the insurance. I understand that the signing of the proposal/ application does not bind me to complete the insurance but agree that should a contract of insurance be concluded, this proposal/application and the statements made therein shall form the basis of the contract.
Form Consent
*
This information will be stored and processed for the purpose of this enquiry and will not be shared, transferred or sold without consent.
Signature
Please verify that you are human
*
Submit
Should be Empty: