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 70th
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:________________________________
|
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
$ |
|
||||||
|
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 |
|
|
|
|
|
|||||