| Insured |
Origin City, Country |
Date Packed |
| Destination (Complete Address) |
Moved By:
[ ] Sea [ ] Air [ ] Land |
| Note: Declare the Replacement Value of all
items in your shipment below or submit your own legible listing of
items and their replacement cost at destination. |
Employer |
| A. ELECTRONICS |
| ARTICLE |
QTY |
REPLAC.
COST |
| Television(s) |
|
|
| Video Recorder(s) |
|
|
| Video Camera(s) |
|
|
| Computer System(s) |
|
|
| Software |
|
|
| Radio(s) |
|
|
| Record Player/Stereo(s) |
|
|
| Tape Deck/Recorder(s) |
|
|
| CD Player(s) |
|
|
| Speakers |
|
|
| Dishwasher |
|
|
| Oven/Range |
|
|
| Microwave |
|
|
Refrigerator/Freezer |
|
|
| Washing Machine |
|
|
| Clothes Dryer |
|
|
| Sewing Machine |
|
|
| Projector(s) |
|
|
| |
|
|
TOTAL Currency |
|
|
|
| B. KITCHEN |
| ARTICLE |
QTY |
REPLAC.
COST |
| Step Stool |
|
|
| Dinette Set |
|
|
| Electrical Appliances |
|
|
| Cabinets |
|
|
| Tables |
|
|
Kitchen Linens & Curtains
|
N/A |
|
| Utensils/Cutlery |
N/A |
|
| Pots and Pans |
N/A |
|
| Bowls, Trays, Etc. |
N/A |
|
| Dishes |
N/A |
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
| |
|
|
| C. LIVING
ROOM |
| ARTICLE |
QTY |
REPLAC.
COST |
| Sofa(s) |
|
|
| Chair(s) – Ottomans |
|
|
| Lamp(s) & Shade(s) |
|
|
| Table(s) |
|
|
| Rug(s) & Carpet(s) |
|
|
| Desk |
|
|
| Curtains & Drapes |
|
|
| Piano or Other Musical Inst. |
|
|
| Bookcase/Room Divider |
|
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
|
| D. DINING
ROOM |
| ARTICLE |
QTY |
REPLAC.
COST |
| Table |
|
|
| Chair(s) |
|
|
| China Closet |
|
|
| Buffet |
|
|
| Serving Table |
|
|
| Tea Cart |
|
|
| Lamps & Chandeliers |
|
|
| Rug(s) & Carpet(s) |
|
|
| Curtains & Drapes |
|
|
| Mirrors |
|
|
| Table Linens |
|
|
| Accessories |
|
|
| |
|
|
TOTAL Currency |
|
|
| |
|
|
| E. CLOTHING/LINEN |
| ARTICLE |
QTY |
REPLAC.
COST |
| Coats/Jackets |
N/A |
|
| Suit(s) |
N/A |
|
| Dresses |
N/A |
|
| Sport Coat(s) |
N/A |
|
| Slack(s) |
N/A |
|
| Sweater(s) |
N/A |
|
| Blouse(s)/Shirt(s) |
N/A |
|
| Skirt(s) |
N/A |
|
| Sleepwear |
N/A |
|
| Shoes/Boots |
N/A |
|
| Hosiery/Socks |
N/A |
|
| Ties/Scarves |
N/A |
|
| Underwear/Lingerie |
N/A |
|
| Sportswear |
N/A |
|
| Sheet(s)/Pillow Cases |
N/A |
|
| Spread(s) |
N/A |
|
| Quilt(s) |
N/A |
|
| Blanket(s) |
N/A |
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
|
| F. BASEMENT
& GARAGE |
| ARTICLE |
QTY |
REPLAC.
COST |
| (Excluding Car) |
| Workbench |
|
|
| Tools: |
|
|
| |
|
|
| |
|
|
| |
|
|
| Lawn Mower |
|
|
| Garden Tools |
|
|
| Furniture (Patio) |
|
|
| Luggage/Trunks |
|
|
| Iron/Ironing Board |
|
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
| |
|
|
| G. CHINA,
CRYSTAL, MARBLE, GLASS, ETC. |
| ARTICLE |
QTY |
REPLAC.
COST |
| Silver: |
|
|
| |
|
|
| |
|
|
| |
|
|
| |
|
|
TOTAL Currency |
|
|
|
| H. BATHROOMS |
| ARTICLE |
QTY |
REPLAC.
COST |
| Rugs, Toilet Covers |
N/A |
|
| Toilet Articles |
N/A |
|
| Medical Supplies |
N/A |
|
| Towels, Etc. |
N/A |
|
| Clothes Hamper |
N/A |
|
| Trash Can |
N/A |
|
| Cabinets, Shelves, Mirrors |
N/A |
|
| Razors, Hair Dryers |
N/A |
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
| |
|
|
| I. BEDROOM
NO. 1 (Master) |
| ARTICLE |
QTY |
REPLAC.
COST |
| Chair(s) |
|
|
| Bed(s) |
|
|
| Night Table(s) |
|
|
| Dress. Table/Vanity |
|
|
| Bench |
|
|
| Chest & Drawers |
|
|
| Mirror(s) |
|
|
| Rug(s) |
|
|
| Lamp(s) |
|
|
| Curtains & Drapes |
|
|
| Bookcase(s) |
|
|
| Desk(s) |
|
|
| Armoire/Wardrobe |
|
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
|
| I. BEDROOM
NO. 2 |
| ARTICLE |
QTY |
REPLAC.
COST |
| Chair(s) |
|
|
| Bed(s) |
|
|
| Night Table(s) |
|
|
| Dress. Table/Vanity |
|
|
| Bench |
|
|
| Chest & Drawers |
|
|
| Mirror(s) |
|
|
| Rug(s) |
|
|
| Lamp(s) |
|
|
| Curtains & Drapes |
|
|
| Bookcase(s) |
|
|
| Desk(s) |
|
|
| Armoire/Wardrobe |
|
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
| |
|
|
| I. BEDROOM
NO. 3 |
| ARTICLE |
QTY |
REPLAC.
COST |
| Chair(s) |
|
|
| Bed(s) |
|
|
| Night Table(s) |
|
|
| Dress. Table/Vanity |
|
|
| Bench |
|
|
| Chest & Drawers |
|
|
| Mirror(s) |
|
|
| Rug(s) |
|
|
| Lamp(s) |
|
|
| Curtains & Drapes |
|
|
| Bookcase(s) |
|
|
| Desk(s) |
|
|
| Armoire/Wardrobe |
|
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
|
| L. DEN/FAMILY
ROOM |
| ARTICLE |
QTY |
REPLAC.
COST |
| Chair(s) |
|
|
| Curtains & Drapes |
|
|
| Sofa |
|
|
| Table(s) |
|
|
| Lamp(s) |
|
|
| Rug(s) & Carpeting |
|
|
| Desk |
|
|
| Bookcase(s) |
|
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
| |
|
|
| M. MISCELLANEOUS |
| ARTICLE |
QTY |
REPLAC.
COST |
| Typewriter(s) |
|
|
| Clock(s) |
|
|
| Bric-a-brac |
N/A |
|
| Baskets, Plant Holders |
N/A |
|
| Toys & Games |
|
|
| Food |
N/A |
|
| Wine/Liquor |
|
|
| Sewing Supplies |
N/A |
|
| Cutting Table |
|
|
| Sports Equipment |
|
|
| Pictures/Paintings |
|
|
| Camera(s)/Lens |
|
|
| Misc. Camera Equip. |
|
|
| Boos/Records/Tapes/Film |
|
|
| Fireplace Equipment |
|
|
| Bicycle(s) |
|
|
| Other |
|
|
| |
|
|
TOTAL Currency |
|
|
|
| N. AUTOMOBILE |
Year/Make:
|
Serial Number (VIN):
|
Replac. Cost at Dest.:
|
Non-factory installed auto accessories must
be separately listed and valued.
|
|
| |
|
|
| SUMMARY |
| A. Electronics |
|
| B. Kitchen |
|
| C. Living Room |
|
| D. Dining Room |
|
| E. Clothing/Linen |
|
| F. Basement & Garage |
|
| G. China, Crystal, Etc. |
|
| H. Bathrooms |
|
| I. Bedroom 1 (Master) |
|
| J. Bedroom 2 |
|
| K. Bedroom 3 |
|
| L. Den/Family Room |
|
| M. Miscellaneous |
|
| N. Automobile |
|
| O. Other |
|
| TOTAL |
|
| Freight Costs |
|
| GRAND TOTAL |
|
| Currency: |
|
|
|
|
|
|
