CUMULATIVE FORM – APPLICATION and INVENTORY For International Moves Only

For insurance coverage For Household Goods & Personal Effects only

Kindly Mail to: Revivim Ltd. (or give to your Shipper): 93-02 70^th Ave., Forest Hills, N.Y. 11375

Toll Free: 1-800-411-0913 Tel: 718-544-5678 Fax: 718-793-4021 Email: info@revivim.com

Name of Assured: _______________________________________________________________________________

Current Address: ________________________________________________________________________________

Residing at the Address Above Until:_______________ Name of Mover:_______________________________

Final Destination of Shipment: Street______________________________________________Number_______

City_____________________State/Country________________________Zip_________Tel#_______________

Email Address:_____________________________________________________________________________

Mode of Shipment: ¨ Sea ¨ Air

Name of Ship/Airline (if known): ____________________________________________________________________

Estimated Date of Shipment: ____________________________ Pick-up Date: _____________________________

Shipment Packed in: ¨ Individual Container ¨ Lifts/Combined Container

Cover Type: ¨ “All Risks” subject to “Section-1” ¨ “Limited Cover” subject to Section-2”

of the “Scope of Cover” of the “Conditions and Warranties” attached.

Deductible: Policy will be subject to a deductible as shall be mentioned in the “Confirmation of Insurance”

to be issued.

Note: Coverage requires full reporting of the entire shipment. Actual cash value is defined as replacement cost less depreciation. Shipment insured for less than actual cash value will be subject to the 100% Co-Insured Clause as noted on the “Confirmation of Insurance”. Items grouped together in value will be assumed to be of equal value. Please attach additional pages if necessary.

Calculation of Inventory:

Total Page 2 (line 115a) $____________

Total Page 3 (line 228a) $____________

Total Page 4 (line 336a) $____________

Grand Total Marine Insurance at destination $_____________ X _________% = $_____________ premium to be paid

Air Insurance Value at destination $_____________ X _________% = $_____________ premium to be paid

Car Insurance Value at destination $_____________ X _________% = $_____________ premium to be paid

Fill out Automobile Details on separate form

Shipping Charges $_____________ X _________% = $_____________ premium to be paid

Handling Fees: $30.00 $________30.00

TOTAL PREMIUM TO BE PAID $_____________

MINIMUM PREMIUM $50.00 Enclosed is a cheque for $_____________ payable to Revivim Ltd

Goods must be insured for their full value in Israel. The multiplication factors appearing in this list are for reference only.

Please indicate below the date when the policy should become effective (The date on which the first item to be insured is in the custody of the movers) Date: _____________________________

Cover is valid only if and after a “Confirmation of Insurance” has been issued and will be subject to the terms and conditions therein. Said “Confirmation of Insurance” should be obtained by you from our office or your forwarder prior to shipment.

I desire to effect insurance on my household goods and personal effects as arranged by Revivim Ltd in the amounts noted above. I agree that this application shall be taken as the basis for the proposed contract between myself, Revivim Ltd as brokers for Atlas Insurances Ltd - Lloyd’s Coverholders and their underwriters. I understand the Mover/Forwarder/Packer is acting as “Agent for the Insured” in securing this coverage. The Mover/Forwarder/Packer is not a Revivim Ltd and/or Atlas Insurances Ltd agent and has no authority to change or modify any condition of coverage. I hereby declare that all the information in this cumulative form is correct.

Signature: ________________________________________ Date:________________________________

INVENTORY: Mr./Mrs. __________________________________________________________________________

No.	Qty	Large Electrical Appliances	Price per Unit $	Total $	No.	Qty	Small Electrical Appliances	Price per Unit $	Total $
1		Refrigerator			58		Egg cooker
2		Deep freezer			59		Electric blanket
3		Dishwasher			60		Electric kettle
4		Washing machine			61		Electric knife
5		Clothes dryer			62		Fan/Ventilator
6		Air conditioner			63
7		Stove range			64		Fondue
8		Microwave oven			65
9		TV (color)			66		Food processor
10		TV (B & W)			67
11		Plasma screen			68		Garbage disposal
12					69
13					70		Hand mixer
14					71		Hair dryer
15		Paint sprayer			72		Heater
16					73		Hot dogger
17		Saw (Electric)			74
18		Sewing machine			75		Humidifier
19		Shaver			76
20		Slide projector			77		Ice-cream maker
21					78		Iron
22		Telephone			79
23		Toaster			80		Juice extractor
24		Toaster oven			81		Meat grinder
25					82		Mixer
26		Typewriter			83		Monitor
27					84		Movie projector
28		TV game			85
29		Vacuum cleaner			86
30		Yogurt maker			Stereo System
31					87
32					88		Receiver
33		Answering machine			89
34		Fax machine			90		Turntable
35					91
36					92		Speakers
37					93
38					94		Cassette recorder
39					95
40					96		Tape recorder
41					97
Small Electrical Appliances					98		Stereo amplifier
42		Alarm clock			99
43		Clock radio			100		Tuner
44		Digital clock			101
45		Wall clock			102		Headphones
46		Barbeque grill			103
47		Broiler			104		Radio
48		Blender			105
49					106
50		Calculator			107		Compact disc
51		Can opener			108
52		Coffee maker			109		VCR
53		Coffee grinder			110		DVD
54		Corn popper			111
55					112
56		Drill			113
57	Total this column (1-56) $				114	Total this column (58-113) $
Goods must be insured for their full value at Destination.					115	Total this page (57 + 114) $
					115a	Multiply Row 115 X2 $

INVENTORY: Mr./Mrs. _____________________________________________________________________

No.	Qty	Furniture	Price per Unit $	Total $	No.	Qty	Children’s Items	Price per Unit $	Total $
116		Armchair			173
117		Bar			174
118		Bedroom			Musical Instruments
119		Beds & mattresses			175		Accordion
120		Bookcase			176		Drums
121		Chairs			177		Flute
122		Coffee table			178		Guitar
123		Corner table			179		Organ(**)
124		Couch (sofa)			180		Piano(**)
125		Desks			181		Saxophone
126		Dinette/Kitchen set			182		Violin
127		Dining table			183		Xylophone
128		Dining room set			184
129		Dresser			185
130		Dressing table			Sports & Camping Equipment
131		Fixture			186		Air gun
132		Garden furniture			187		Bicycles
133		Lamps			188		Boat
134		Love seat			189		Boat engine
135		Make-up mirror			190		Cooler
136		Mirrors			191		Diving equipment
137		Night table			192		Fishing equipment
138		Recliner			193
139		Rocking chair			194		Gas lamp
140		Rugs & carpets(*)			195		Gas stove
141		Shelves			196		Sleeping bags
142		Tables			197		Ski equipment
143		Tea wagon			198
144		Toilet table			199		Tent
145		TV table			200		Tennis equipment
Children’s Items					201		Telescope
146		Bathtub			202		Thermos
147					203		Water ski equipment
148		Car safety seat			Various Household Items
149		Carriage			204
150		Crib			205		Bath acc.
151					206
152		Dressing table			207		Bath mats
153					208
154					209		Blankets
155		Games			210
156					211		Blanket cover
157					212
158					213		Bedspreads
159		High chair			214
160					215		Curtains
161					216
162		Mattress			217		Comforters
163		Nursery Scale			218
164					219		Sheets
165		Stroller			220
166					221
167					222
168