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					223		Pillows
169		Walker			224
170					225		Towels
171					226
172	Total this column (116-171) $				227	Total this column (173-226) $
Goods must be insured for their full value at Destination.					228	Total this page (172 + 227) $
					228a	Multiply Row 228 X2 $
(*) (**)	Include a detailed assessor’s valuation for Persian, Chinese etc. carpets, insured value of which is over $1,000. Subject to a detailed assessor’s value. pianos & organs must be crated separately.

INVENTORY: Mr./Mrs. _____________________________________________________________________

No.	Qty	Various Household Items	Price per Unit $	Total $	No.		Qty	Clothing	Price per Unit $	Total $
229					283			Men’s clothing
230					284
231		Tablecloth			285
232					286			Suits
233					287
234					288
235					289			Shoes
Dining & Kitchenware					290
236		Chinaware			291
237					292			Handbags
238					293
239		Corning ware			294
240					Arts & Crafts(*) Books & Records(**)
241
242		Crystal ware			295			Books(**)
243					296
244					297
245		Dinner sets			298
246					299			Ornaments-crafts(*)
247					300
248		Flatware (silver)			301
249					302
250		Flatware (steel)			303			Paintings(*)
251					304
252		Glassware			305
253					306
254					307			Posters
255		Pots & pans			308
256					309
257					310			Records(**)
258		Pyrex ware			311			Cassettes(**)
259					312			Video tapes(**)
260		Stainless tableware			313
261					314			Sculptures(*)
262		Utensils			315
263					316
264					317
265					318
Clothing					Misc.
266		Children’s clothing			319			Personal computer
267					320			Computer screen
268					321			Scanner
269					322			Printer
270					323
271		Coats			324
272					325
273					326
274		Fur coat(*)			327
275					328
276					329
277					330
278					331
279		Leather coats			332
280					333
281					334
282	Total this column (229-281) $				335	Total this column (283-334) $
Goods must be insured for their full value at Destination.					336	Total this page (282 + 335) $
					336a	Multiply Row 336 X2 $
(*)Include a detailed assessor’s valuation for objects of value such as fur coats, arts and craft, insured value of which is over $1,000. (**)Should be itemized according to categories or boxes.

^{Atlas Insurances} Sample Conditions and Warranties (Personal Effects)

***The Certificate of Insurance is the binding document at all times.***

INTEREST INSURED
Household goods and personal effects, private cars and motorcycles in containers, as per inventory declaration submitted by the Assured, and forming the basis of insurance under this certificate.
WARRANTED :
1. The premium due hereon including any additional premium, has been paid in full and funds have been collected by ATLAS INSURANCES LTD (The Company).
2. Supplementary documents (cumulative form and inventory list) have been submitted with the application and approved by the Company.
3. Fine art objects, paintings, prints, antiques, sculptures, furs, rugs, carpets, runners and all other similar valuables valued at more than $1,000 each (replacement value) will be accepted for insurance only if accompanied by a qualified expert's appraisal with the corresponding sum insured at conditions and premium to be agreed.
4. Method of Transit: per approved vessel and /or carrier. Date of dispatch to be declared as soon as practicable to the company or its representative with the following details: name of vessel, voyage number, date of sailing and/or date of arrival.

SCOPE OF COVER
Always subject to the due premium having been paid and funds collected by the company and subject to the terms and conditions of the policy.
Household goods and personal effects are covered against the risks of physical loss or damage to the property insured from external cause, as applicable per one of the following sections, which is agreed upon and stated in the Confirmation of Insurance.

SECTION 1: All Risks of physical loss or damage to the subject matter insured as per London Institute Cargo Clauses (A) Cl.252 dated 1.1.82 . PROVIDED that the Assured gave clear instructions in writing to the company to provide such cover, and the insurers, agreed thereto, otherwise the coverage is limited to SECTION 2 only below.

SECTION 2: As per London Institute Cargo Clauses (C) Cl. 254 dated 1.1.82 covering the following perils only:
Loss of or damage to the subject-matter insured reasonably attributable to fire or explosion; vessel or craft being stranded, grounded, sunk or capsized; overturning or derailment of land conveyance; collision or contact of vessel craft or conveyance with any external object other than water; discharge of cargo at a port of distress. Loss of or damage to the subject matter insured caused by General Average sacrifice; jettison.

FOR BOTH SECTIONS (1 AND 2 ABOVE)
Including War, Strikes, Riots and Civil Commotions as per London Institute War and Strikes Clauses and to Termination of transit clause (Terrorism) J.C.2001/056. Subject to London Classification Clause & Institute Radioactive Contamination Chemical, Biological, Bio-Chemical and Electromagnetic Weapon Exclusion Clause Cl.370 of 10.11.03 , Institute Cyber Attack Exclusion Clause Cl .380 of 10.11.03, Cargo ISM Endorsement JC98/019 of 1.5.98
Used motor-cars/motor-cycles are insured as per Institute Cargo Clauses (C) 1.1.82 only and not as elsewhere stated. Including the risk of theft and non - delivery of the entire car/motor-cycle but only after being delivered to port of shipment.
NO COVERAGE while vehicles, whether new or used, are driven by their own power. Excluding third party liability/risk of whatsoever nature in all cases.

CONDITIONS
1. Co-Insurance Clause: The Assured shall at all times maintain insurance on 100% value of his personal effects/household goods to the extent of the actual cash value i.e. replacement cost at destination at the time of loss or damage and failure to do so, the Assured, shall to the extent of such deficit, bear his or their proportionate share of any loss or damage including labor charges.
2. All consignments must be professionally packed and subject to customary and adequate packing for the respective item and entered on the mover's packing list.
3. It is a condition of this Insurance that in the event of total loss or damage, the maximum liability of the insurer shall be the replacement value of the item or of a comparable item in the condition at the time of loss or damage, not exceeding the insured value of said item. The Insurer shall be entitled at his sole option to replace with like kind and quality, or repair any article damaged (whether wholly or in part ) or to pay cash, in any event not exceeding the insured value thereof. Always provided that in the event of replacement or cash payment for actual or constructive total loss or damage, the item is surrendered to and becomes the property of the Insurer if he so desires at his sole discretion.
4. Any electrical items, appliances or other valuable items not declared on the Customs Entry cannot be claimed, nor alleged to have been lost or damaged.
5. Pianos, organs and musical instruments must be professionally packed and individually crated.
6. Pairs and Sets Clause: Where any insured item consists of articles in a pair or set including all crockery, dishes, glassware or furniture sets, this Certificate shall not pay more than the proportionate value of any particular part or parts which may be lost or damaged without reference to any special value which such article or articles may have as part of such pair or set.
7. In case of missing item/s the Assured has to provide the insurer satisfactory documentary evidence for each such missing item.
8. Notwithstanding anything to the contrary herein it is hereby declared and agreed between the insurer and the Assured, that the insurer being precluded from examining the cumulative form and inventory list (hereinafter Cumulative Form) at the inception of the insurance, the inclusion of any item or items in the said Cumulative Form and of the value stated in respect of such item or items shall not bind the insurer, notwithstanding that a Confirmation of Insurance has been issued in respect of the total amount of such Cumulative Form. In the event of any item/s being outside the scope of this insurance, this Certificate shall not be deemed to cover such item/s and the insurer shall return to the Assured the proportionate part of the premium.
9. The actual value and the limit of the amount recoverable in respect of any item lost or damaged must be proved by the Assured to the insurer -the maximum amount recoverable being the sum insured or the replacement value at destination, whichever is the lower.
10. In case of claim for damage or shortage, the Assured has to prove that the loss occurred during the transit. Such losses are covered only if there will be signs on the external packing.

DURATION OF TRANSIT CLAUSE
Subject to the Issuance Date mentioned in the policy, coverage attaches from the time the household goods and personal effects are being professionally packed and picked up at the residence or business location of the insured for the commencement of the transit and continues during the ordinary course of transit, including customary transshipment, if any, until the insured property is delivered to the first destination after discharge but not later than 60 days after discharge from the carrying Vessel/Airplane at final port of discharge.
The policy includes storage coverage for up to 60 days prior to the goods being loaded onto ship or plane but only if and while stored in the export forwarder's warehouse, Port or any bonded warehouse and against the following risks ONLY: Fire, Water Damage and Burglary.
Notwithstanding anything to the contrary herein, all new purchases are covered only after warehoused by packer/shipper, and not in transit from the retailer.

EXCLUSIONS
Notwithstanding anything contained elsewhere here in to the contrary, this insurance does not cover:
1. Missing items, breakage, scratching, denting, chipping, staining and tearing of owner-packed articles /cartons / boxes.
2. Loss or damage caused by gradual deterioration, wear and tear, atmospheric or climatic conditions, inherent vice, electrical, electronic and mechanical derangement.
3. Depreciation arising from inadequate or substandard repairs or restoration of a damaged item.
4. Marring, scratching, chipping and denting of used electrical appliances and used furniture.
5. Loss of cash, coins, bills, banknotes, jewelry, gold and silver articles, commercial papers, cheques, money orders, travelers cheques, traveling tickets, stamps, valuable documents, film, eye-glasses and items which derive their value from their artistic and collectable nature.
6. Loss or damage caused by or due to termites, rodents, moths, vermin, rust, mold, seizure or confiscation by authorities, consequential loss or damage.
7. Commercial shipments and all goods or interest other than Personal & Household Effects.
8. Alcoholic and other beverages and food of any kind and/or damage caused thereby.
9. Loss or damage directly or indirectly caused by earthquake, volcanic eruptions and other cataclysms when on land.
10. Loss or damage due to mysterious disappearance and/or unexplained shortage.

AUTOMOBILE AND MOTORCYCLE
Notwithstanding anything to the contrary, coverage commences from the time the Automobile or Motorcycle is warehoused in the custody of the Freight Forwarder or Steamship Company and terminates upon discharge at port of destination, provided it is loaded on the vessel in strict compliance with all safety measures of carriage.
Notwithstanding anything to the contrary, the risk of theft and Non-Delivery attaches only upon delivery of the motorcar or motorcycle to the port of shipment.
In no case the vehicle is insured against third party risks/liability nor whilst driven under its own power.
It is further agreed and understood that this certificate does not cover any damage, injury or liability to third party under any law/regulation requiring vehicles to be insured against third party risks or liability or otherwise.

IMPORTANT NOTICE TO ASSURED
The attention of the Assured and/or Cargo Receiver is drawn hereby to the condition of the insurance whereby they are required to act at all times with reasonable dispatch in all matters concerning the handling of the goods insured. They are specifically required:
1. To clear the goods from Customs without delay and even before arrival of the vessel, make all necessary arrangements for taking delivery of the goods immediately as soon as they are discharged.
2. To take all possible precautions with a view to avoiding any damage or loss and preventing the aggravation of damage or loss already sustained.
3. To keep damaged or broken items in their original packing and to present them to the surveyor on demand. No damages may be repaired without Insurer's authorization and any unauthorized repairs are entirely at the Assured's risk and expense.
 4. To cooperate with the surveyor of the insurance company for immediate dealing with the damage and/or loss. Any delay in taking delivery of the goods for reasons which could be foreseen and within the control of the Insured or their representatives shall not be deemed a justified delay and may prejudice the claim for a sustained damage and/or loss.

LIABILITY OF CARRIERS, BAILEES OR OTHER THIRD PARTIES
The Assured or his agents must:
1. Claim immediately on the carriers and on the port authorities for any missing packages.
2. Apply immediately for survey in the docks by carriers' representative if any loss or damage be apparent and claim on the carriers for any actual loss or damage found at such survey.
3. In no circumstances, except under written protest, give clean receipts where goods are in doubtful condition.
4. Give notice in writing to the carrier's representative within three days of delivery if the loss or damage was not apparent at the time of taking delivery.
Note: The Assured or his agents are recommended to make themselves familiar with the regulations of the port authorities at the port of discharge.
Any claim under this insurance should be submitted without delay accompanied by all correspondence with carriers and other parties regarding their liability.

PROCEDURE OF CLAIM
In case of a claim, the Assured must give immediate written notice to Atlas with all supporting documents, including where applicable:
1. Atlas' 'Claim Form' filled ( http://www.atlas-insurances.com/ClaimFormP.pdf )
2. Copy of Confirmation of Insurance.
3. Copy of 'Cumulative Form-Application and Inventory' as you filled in before shipment.
4. Bill of Lading and/or other contract of carriage.
5. Any documentary evidence to show the extent of the loss or damage ( incl. photos, written professional estimates for repair of damage ).
6. Copy of delivering carrier's receipt with exceptions noted.
7. Port Authority's loss or damage certificate.
THE CONSIGNMENT INSURED HEREUNDER MUST BE ATTENDED BY THE ASSURED OR HIS REPRESENTATIVE DURING THE INSPECTION AT PORT OF DISCHARGE AND THENCE UNTIL FINALLY RE-PACKED FOR TRANSPORTATION. THE ASSURED SHOULD ALWAYS ACT AS IF HE WERE UNINSURED.