Pac Global Insurance Brokerage, Inc.
WORLDWIDE MARINE INSURANCE
"We are known by the companies we represent."
WORLDWIDE ALL RISK DOOR-TO-DOOR INSURANCE FOR HOUSEHOLD GOODS,
PERSONAL EFFECTS AND PRIVATE AUTOMOBILES
Insurance Agreement
And Application
The attached insurance agreement and application contain important terms, conditions and exclusions.
Please read all pages carefully.
Make sure you have followed these important steps:
Review the coverage terms, conditions, exclusions and explanations found on the attached pages.
- Please retain the pink copy of this document set for your records. Return all·other copies to your mover before the shipment departs.
- Carefully and accurately complete the attached Application Form. You are required to state the actual value of your goods. The value stated must be the worth of your property at the place of your new residence.
We hope you have a successful and uneventful move. However, if you have problems, we'll work with you to get your problems resolved promptly and equitably.
Best wishes to you in your new home.
Administered by: Pac Global Ins. Brokerage, Inc.
898 Sepulveda Blvd., Suite 700
EISegundo,CA 90245
Phone: (310) 227-8500
Fax: (310) 227-8511
E-mail: general@pacglobalins.com
PAC GLOBAL INSURANCE BROKERAGE, INC.
FREQUENTLY ASKED QUESTIONS ABOUT MARINE INSURANCE FOR PERSONAL EFFECTS
ABOUT THIS INSURANCE PROGRAM: The insurance company from which you are purchasing this insurance has designated Pac Global Insurance Brokerage, Inc. as its program administrator. PAC GLOBAL INSURANCE BROKERAGE, INC. specializes in the administration of marine insurance programs. All questions, comments and claims in relation to this insurance must be addressed directly to PAC GLOBAL INSURANCE BROKERAGE, INC. by telephone at: 310.227.8500 or via e-mail at: general@pacglobalins.com. Your professional mover is not an agent of the insurance company or PAC GLOBAL INSURANCE BROKERAGE, INC.
WHY SHOULD MY HOUSEHOLD GOODS BE INSURED?: Your household goods will be exposed to the risks of loss or damage regardless of whether the move is across the street or around the world. No matter how careful your professional mover might be, many hazards are unavoidable, or uncontrollable. Your household goods may come into contact with multiple shipping companies which either limit their liability for damage or are immune from claims. Sophisticated commercial shippers understand these risks and therefore generally protect their interests by purchasing cargo insurance.
WHAT GENERAL COVERAGE IS PROVIDED?: With this insurance protection, your belongings will be insured against “All Risk” of physical loss or damage from any external causes. Your property will be covered from the time it enters the custody of the mover until unpacked at your new residence, including the period of due transit as well as an additional period of up to 60 total days of warehouse storage whether at place of origin residence or at warehouse storage at place of destination residence. If for any reason your property will be subject to any additional period of storage beyond the stated coverage parameters, it will be your responsibility to arrange for an extension of the insurance coverage. A separate extension form is attached to the application.
DOES THIS INSURANCE HAVE LIMITATIONS AND EXCLUSIONS?: Yes, all insurance policies contain coverage limitations, restrictions, exclusions and conditions precedent to the attachment of coverage. For this reason, it is very important for you to carefully review the policy “Terms and Conditions” contained on the following pages.
WHAT IS THE “DECLARATION OF INSURANCE?: The original Declaration of Insurance is evidence of your insurance coverage. This important document confirms the amount of insurance you have arranged and contains the governing policy “Terms and Conditions.” Your Declaration of Insurance will be supplied to you by your moving professional following receipt of the Application Form. The Declaration of Insurance is evidence of your insurance and includes instructions on filing a claim. Please keep it in a safe place.
WHY IS IT IMPORTANT TO ACCURATELY VALUE MY GOODS?: Under no circumstance is the value of any item agreed upon; items subject to claim will be evaluated for market value at destination. Still, you are required to insure for the full replacement value at destination of all shipped items. This is because the amount of your premium payment for coverage is based upon valuation and commensurate risk to the insurance company. Accordingly, shipments which are insured for less than full replacement value at destination shall be subject to the “Co-Insurance Penalty.”
The “Co-Insurance Penalty” means that payment by the insurance company on any claim otherwise covered under this policy shall be reduced in accordance with the ratio in which the shipment was underinsured. As example only, if you purchase US$5,000 of insurance for a US$50,000 shipment, and one item worth $100 is lost or destroyed, you will only be paid US$10 (US$5,000/US$50,000 X US$100). This is called a co-insurance penalty, as you are penalized for failure to buy adequate insurance for the entire shipment.
IS IT IMPORTANT TO ACCURATELY & SEPARATELY IDENTIFY AND VALUE EACH ITEM I WANT TO INSURE?: There are two methods to value your shipment –
You may specifically identify and accurately value each and every item you want to insure. The maximum value which will be paid by the insurance company for any item is your declared value for that item or the replacement value at destination – whichever is the lower. If you have items that do not fit within a category on the application and do not mention them specifically under Category “M - Other,” such items are not covered by this insurance. By way of example only, if a computer, software, purse, umbrella or pair of sunglasses is lost or destroyed, and you have not added the item to the category of “Other,” you will not be paid for that item. This is the preferred method to value your shipment because experience indicates you are less likely to incur the “Co-Insurance Penalty” described above.
Alternatively, you can declare a “lump sum” figure for the total collective value of your shipment, in all events for a sum no less than EUR 5,000 per cubic meter.
Under both methods of valuation, high value items must be specifically and separately declared and valued.
WHAT ARE “HIGH VALUE ITEMS”?: Any individual item in your shipment having a value of EUR 5,000 or more is a “High Value Item.” Each such item must be individually and separately listed with its full replacement value at destination on a separate sheet attached to your application, which can be provided upon request. Your failure to separately identify and value any item in the shipment having a value of EUR 5,000 or more will in all events limit claim recovery for damage or loss of that item to a maximum of EUR 5,000.
WHAT IF MY GOODS MOVE AS SEPARATE SHIPMENTS?: If you have separate shipments, such as one by air and one by sea, or one to remain in storage, each shipment must be separately insured.
HOW DO I REQUEST THIS INSURANCE COVERAGE?: After you fully review this page and policy “Terms and Conditions” contained on the following pages, carefully and accurately complete and sign the Application Form. Return the Application Form to your authorized mover and arrange for payment of the premium. Your professional mover will then give you the Declaration of Insurance.
WHAT IF I HAVE A CLAIM?: In the event of a claim, refer to the "Claim Procedure" instructions attached to your Declaration of Insurance. You must give written notice of claim within 7 days after delivery of your goods, or in the event of non-delivery, within 7 days of the date your goods should have been delivered, and in all events within 7 days from the last day of coverage period. Otherwise there shall be no coverage.
TERMS AND CONDITIONS
CAUTION: BE SURE YOU READ, UNDERSTAND, AND COMPLY WITH ALL TERMS AND CONDITIONS. FAILURE TO COMPLY WITH ANY OF THE TERMS AND CONDITIONS MAY RESULT IN REDUCTION OF THE RECOVERABLE AMOUNT OR COULD INVALIDATE THE POLICY ENTIRELY.
INTEREST INSURED: Household goods and personal effects, private car, mobile home and/or motorcycle used for the private purpose of the Insured only, as per declaration/inventory submitted by the Insured, forming the basis of insurance under this Policy.
SCOPE OF COVERAGE: Always subject to the full premium having been paid to and collected by Pac Global Insurance Brokerage, Inc., and subject to all Terms And Conditions of this Policy, new and/or used household goods and personal effects, under deck, are insured against ALL RISKS of direct physical loss or damage from any external cause, irrespective of percentage (Current American Institute Cargo Clause), including General Average and Salvage Charges, and transshipment, if involved. Shipments on deck of ocean vessel subject to an “On Deck” Bill of Lading are warranted free of particular average. Containerized shipments on deck are insured per above “All Risk” clauses.
METHOD OF TRANSIT: Per approved vessel and/or truck and/or air carrier and/or rail carrier and/or conveyances held covered. Date of dispatch to be declared as soon as practicable to Insurer or its representative with the following details: name of vessel or carrier, voyage or flight number, bill of lading and container number as well as date of departure and/or date of arrival.
R.A.C.E. CLAUSE: This Insurance is subject also to the Current London Institute Radioactive Contamination Exclusion Clause and related U.S.A. Endorsement.
FPA CLAUSE (if applicable or elected):
FPA – Warranted free of particular average (providing coverage only in the event of total loss or destruction or constructive total loss) unless vessel or craft be stranded, sunk or burnt, jettison or washing overboard. The Insurer to pay any loss or damage to the interest insured which may reasonably be attributed to fire, collision or contact of the vessel and/or conveyance with any external substance (ice included), other than water, or to discharge of cargo at port of distress.
Shore Perils – Where this insurance by its terms covers goods while on docks, wharves or elsewhere on shore, and/or during land transportation, it shall include the risks of collision, derailment, overturning or other accident to the conveyance, fire, lightning, sprinkler leakage, cyclones, hurricanes, earthquakes, floods (meaning the rising of navigable waters), and/or collapse or subsidence of docks or wharves, even though the insurance be otherwise F.P.A.
PERIOD OF COVERAGE & CONDITIONS PRECEDENT TO COVERAGE:
Coverage is to apply from such time as the property enters the custody of the mover until unpacking is completed at destination residence, including course of due transit as well as an additional period of up to 60 days of warehouse storage whether at place of origin residence or after arrival at warehouse storage at place of destination residence. If for any reason the property will be subject to any additional period of storage beyond the stated coverage parameters, it shall be the Insured's sole responsibility to seek coverage extension. Such requests for coverage extensions may be granted subject to prior written notice and payment of additional premiums to Pac Global Insurance Brokerage, Inc., as per application by the Storage Extension Request Form, forming part of this Policy. Extension is subject to written approval of and validation by Pac Global Insurance Brokerage, Inc.
It is a condition precedent to coverage that written notice of claim under this insurance in all events be submitted in accordance with "CLAIM PROCEDURE" within 45 days after the date of delivery of the shipment, or in the event of non-delivery, within 45 days of the date your goods should have been delivered, and in all events within 45 days from the last day of coverage period per paragraph "A" above.
CONDITIONS AND EXCLUSIONS:
Valuation Clause: For coverage hereunder, the Insured must value the shipment in one of two methods: (a) the Insured may specifically identify and accurately value each and every item; items not identified or valued will not be covered. Alternatively, (b) the Insured may declare a “lump sum” figure for the total collective value of the shipment which figure should in no event be lower than EUR 16 per pound of the net weight of the shipment or EUR 5,000 per cubic meter.
Note - Under both methods of valuation, high value items must be specifically and separately identified and declared per paragraph number 4 of these conditions and exclusions.
Co-Insurance Penalty Clause: Regardless of by what method the Insured values the shipment, the Insured must procure insurance for 100% of the value of the entire shipment (replacement cost at destination at the time of shipment). In the event of a claim, failure to buy adequate insurance will result in the Insured having to bear the extent of such deficit by way of “Co-Insurance Penalty.” As an example only, if USD5,000 of insurance is purchased for a USD50,000 shipment, and one item worth USD100 is lost or destroyed, the Insured will only be paid USD10 (USD5,000/USD50,000 X USD100).
This Is Not An Agreed Value Policy: Notwithstanding anything to the contrary herein, it is hereby declared and agreed that in case of a claim arising in respect of all or any item or items appearing on the Declaration/Inventory list, the value reflected against such item or items shall not be regarded as an agreed value between the Insurer and the Insured, notwithstanding that a Declaration of Insurance has been issued in respect of the total amount or amounts of such Declaration/Inventory. The actual value and amount recoverable in respect of each and every item lost or damaged will have to be provided and established by documentation of third-party sources at the sole burden and expense of the Insured, subject to examination, re-evaluation and approval by the Insurer. In all events, the maximum amount recoverable sum for each and any item is the declared value or the replacement value at destination, whichever is determined the lower.
High Value Items Clause: High Value Items are ANY ITEM OVER EUR 5,000 in value, which must be individually and separately listed with full replacement value at destination on a separate sheet. The Insured’s failure to separately identify and value any item in the shipment having a value of EUR 5,000 or more will in all events limit claim recovery for damage to or loss of that item to a maximum of EUR 5,000, assuming other terms and conditions for coverage met.
Pairs and Sets Clause: Where any insured items consist of articles in a pair or set, this Policy is not to pay more than the value of any particular part or parts (or proportionate part) of such pair or set which may be lost or damaged, without regard to any special value which such article or articles may have as part of such pair or set and without regard to any diminution in value of the pair or set.
Percentage Of Glass, Etc.: Warranted that maximum percentage of Glass, China, Marble, Earthenware and the like does not exceed 15% of the total sum insured, or held covered. The foregoing does not apply if loss or damage is caused directly from, stranding, sinking, or collision of the Vessel or collision or overturn of transporting land conveyance. The foregoing does not apply if such articles were professionally and suitably packed.
Repair and Replacement Clause: The Insurer shall be entitled at its 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 declared value thereof. In the event of replacement or cash payment for actual or constructive total damage, the item is surrendered to and becomes the property of the insurer.
Depreciation: Underwriters liability is restricted to the reasonable cost of repair and no claim is to attach hereto for diminution in value consequent thereon.
General Average and Salvage Charges: General Average and Salvage Charges payable as provided in the respective contract of carriage/affreightment. For the purpose of claims for general average contribution and salvage charges recoverable hereunder, the subject matter insured shall be deemed to be insured for its full contributory value. General average deposits only payable on General Average deposits receipts.
Other Insurance: This insurance does not cover to the extent of application of any other insurance, whether prior to or subsequent hereto in date and by whomsoever effected directly or indirectly covering the same property, and the Underwriters shall be liable for loss or damage only for the excess value beyond the amount due from such other insurance.
Mold, mildew, or fungi loss shall be covered as a direct result of fire, the direct ingress of water into transporting trailer or ocean container and inclement weather during container loading operations. Other causes of mold, mildew or fungi, including, but not limited to condensation, humidity, atmospheric conditions or changes in temperature are excluded from coverage.
EXCLUSIONS: The following claims are excluded:
Marring, scratching, chipping and denting of used electrical appliances and used furniture.
*This exclusion will be deleted if the owner and mover both agree and both sign a “Certificate of Condition,” or a similar document, stating the condition of the items at the time the same entered the custody of the mover, specifically noting all defects or affirmatively stating the absence of any defect.
Loss or damage due to mechanical, electrical or electronic derangement unless insured item is otherwise damaged and/or mechanical defects covered by a manufacturer’s warranty.
Loss or damage due to mold, vermin, moth, wear and tear and gradual deterioration, termites, rodents, inherent vice, or rust. MOLD: See Condition No. 11
Consequential loss, damages, diminution in value or expenses incurred.
Loss or damage by climatic conditions or extremes of temperature.
Owner Packed Effects – breakage, scratches, denting, marring, chipping, staining and tearing of owner packed effects, including boxes, trunks, suitcases and the like as well as shipping containers, conveyances and the like. Also excluding claims for lost or missing items unless a valued list of contents is supplied by owner prior to commencement of transit.
Loss of or damage to human remains, cash, notes, stamps, coins, deeds, firearms, negotiable documents, traveler’s checks, jewelry, watches, bullion, or similar valuable articles. Such items should be personally carried as allowed by law.
Any claim for damage to particle board, pressboard, and/or engineered wood furniture will be denied due to inherent vice as this furniture is inherently susceptible to damage. The transferee assumes all responsibility for damage which may occur throughout the move including during packing and the unloading of items after delivery to residence.
GOVERNMENT ACTS AND WAR RISK EXCLUSION CLAUSE: This Policy does not cover loss or damage, if any act or event, out of or in the course of which such loss or damage arises, constitutes or is a part of or is committed or happens whether directly or indirectly by reasons of, or in connection with war, invasion, act of foreign enemy, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, military or usurped power, martial law, or the act of any lawfully constituted authority, including seizure, confiscation or rejection by authorities for any reason. In any claim, and in any action, suit or other proceedings to enforce a claim for loss or damage under this Policy, it is agreed that the burden or proving that the loss or damage does not fall within this clause shall be upon the Insured.
DISPUTE RESOLUTION: No action or suit against the Underwriters or its agents for recovery of any claim by virtue of this insurance shall be sustained in any Court of Law, Equity or Arbitration unless commenced within (1) year from the time loss occurred, or, if such limitation is not valid by the law of the place where the policy is issued, within the shortest contractual period of limitation provided by such law. All such suits when timely filed shall be resolved in mandatory arbitration at Los Angeles pursuant to commercial rules of the American Arbitration Association or before the Transportation ADR Counsel, Inc., or pursuant to the rules of the International Chamber of Commerce, if outside the United States. It is agreed that this policy is a contract of marine insurance and the law applicable to any interpretation of this policy and the rights and obligations of the Insurer and Insured hereunder shall be U.S. federal maritime law.
AUTOMOBILES, MOTORCYCLES AND MOBILE HOMES
Coverage is to apply provided the vehicle is not operated under its own power for the whole period of coverage defined above, unless operation under own power occurs whilst on premises of loading or unloading port in which case coverage is still excluded for all third party risks. Coverage for vehicles is subject to the following exclusions/conditions which apply under all circumstances:
All third party risks whilst the vehicle is being driven under own power are excluded and this insurance further does not cover any damages, injury or liability to third party under any law requiring vehicles to be insured against third party risks or liability.
Scratching, denting or marring of automobile, motorcycle or mobile home is excluded unless the freight forwarder and the owner of the automobile, motorcycle or mobile home both agree and sign a “Certificate of Condition & Accessories,” or a similar document, stating the condition of the automobile or motorcycle or mobile home at the time the same entered the custody of the freight forwarder or steamship company, noting all defects, if any, or affirmatively stating the absence of any defect.
Coverage is specifically excluded for non-factory installed accessories or removable items on or within automobiles, motorcycles or mobile homes unless specifically identified and valued in a “Certificate of Condition & Accessories.”
Any coverage whilst on deck specifically excluded.
Apart of the specific conditions mentioned above, coverage in respect to automobiles, motorcycles or mobile homes is subject to the general terms and conditions of the Policy, where they do not conflict with the specific conditions.
INSURANCE CHARGES CLAUSE:
Coverage under this Declaration shall be void if required premium is not received by Pac Global Insurance Brokerage, Inc. Payment to any party other than Pac Global Insurance Brokerage, Inc. shall not be considered payment to Pac Global Insurance.
NOTE: The Insured or his/her agent 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.
CLAIM PROCEDURE:
There are definite time limitations for claim submission and the Insured shall review the Claims Reporting Procedure attached to the declaration. Immediate written notice must be given to Pac Global Insurance Brokerage, Inc. by way of contact information herein. The Insured shall, as a condition precedent to the coverage afforded by this policy, give written notice of claim to Pac Global Insurance Brokerage, Inc. within 7 days after delivery of the shipment, or in the event of non-delivery, within 7 days of the date your goods should have been delivered, and in all events within 7 days from the last day of coverage period. Failure to give such written notice within 7 days will void coverage regardless of cause of loss or damage. Further, it is mandatory that all supporting documents, including those defined to in paragraph number 4 of the Conditions and Exclusions, be provided in a timely fashion not to exceed 7 days of the first notice.
PAC GLOBAL INSURANCE BROKERAGE, INC.
VALUED INVENTORY LIST
898 Sepulveda Blvd., Suite 250, El Segundo, CA 90245
DECLARATION & APPLICATION FORM FOR ALL RISK FULL REPLACEMENT VALUE INSURANCE
THIS IS NOT A CERTIFICATE OF INSURANCE
INSURED:
ORIGIN CITY, COUNTRY:
DATE PACKED:
PACKED IN: Individual Container
Wooden Container
DESTINATION: (COMPLETE ADDRESS)
MOVING BY: (Check one)
SEA AIR
DECLARATION
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.
Insure your shipment accordingly as it will be co-insured if adequate protection has not been secured.
ITEMS NOT DECLARED AND VALUED ARE NOT INSURED
High Value Items valued at over EUR5,000 per item or set MUST BE SPECIFICALLY DECLARED AND VALUED on a SEPARATE SHEET. High Value Items are defined as any item having a replacement value at destination of EUR 5,000 or greater.
A. LIVING ROOM:
E. LINEN/CLOTHING:
H. BEDROOM N. 1 (Master):
L. MISCELLANEOUS:
ARTICLE
QTY.
REPLAC.
ARTICLE
QTY.
REPLAC.
ARTICLE
QTY.
REPLAC.
ARTICLE
QTY.
REPLAC.
COST
COST
COST
COST
Sofa(s)
Coat(s)/Jackets
Chair(s)
Typewriter(s)
Chair(s) - Ottomans
Suit(s)
Bed (s)
Clocks
Lamp(s) & Shade(s)
Dresses
Night Table
Curio
Table(s)
Sport Coats(s)
Dress Table/Vanity
Basket/Holders
Radio
Slack(s)
Bench
Toy & Games
Stereo
Sweater(s)
Chest & Drawers
Food
TV, DVD player
Blouse(s)
Mirror(s)
Liquor
Rugs & Carpet
Skirts(s)
Rug(s)
Wine
Desk
Shirts(s)
Lamp(s)
Computer Sys
Curtains/Drapes
Sleepwear
Curtains/Drapes
Software
Musical Instrument
Shoes
Bookcase
Game Systems
CD Player
Boots
Desk(s)
Sports Equip.
Bookcase
Hosiery/Socks
Armoire/Wardrobe
Pictures/Paint.
B. DINING ROOM:
Ties/Scarves
Other
Camera(s)
Table
Underwear
I. BEDROOM N. 2:
Camera Equip.
Chair(s)
Lingerie
Chair(s)
Projectors
China Closet
Sportswear
Bed(s)
Books/DVDs
Buffet
Night Table(s)
Fireplace Equip
Serving Table
Sheet(s)
Dress. Table
Bicycles
Lamps/Chandeliers
Pillow Cases
Mirror
M. OTHER / ADDITIONAL (SPECIFY):
Rugs/Carpets
Spread(s)
Rug(s)
USE A SEPARATE SHEET IF NECESSARY
Curtains/Drapes
Quilt(s)
Lamp(s)
Mirror
Blanket(s)
Bookcase(s)
Table Linens
Other
Desk(s)
Other
Chest & Drawers
C. KITCHEN:
F. BASEMENT & GARAGE:
Curtains
Step Stool
(Excluding Car)
Armoire
Dinette Set
Workbench
J. BEDROOM N. 3:
Elec. Appliances
Tools:
Chair(s)
Cabinets/Tables
Bed(s)
Kitchen Linens
Night Table(s)
Dishwasher
Lawn Mower
Dresser/Vanity
Oven/Range
Garden Tools
Mirror(s)
COLUMN SUB-TOTAL
-
Microwave
Furniture (Patio)
Rug(s)
TOTAL HOUSEHOLD GOODS
Refrigerator
Luggage
Lamp(s)
EUR
-
Utensils/Cutlery
Washing Machine
Desk(s)
* TOTAL HIGH VALUE ITEMS
Pots & Pans
Ironer/ Board
Curtains/Drapes
(as per attached declaration if applicable)
Bowls, Trays, Etc
Clothes Dryer
Bookcases
EUR
-
Dishes
Other
Armoire
AUTOMOBILE:
Other
G. BATHROOMS:
Other
Yr./Make:
D. CHINA, CRYSTAL, MARBLE, GLASS, ETC
Rugs
K. DEN/FAMILY ROOM:
Serial No.:
(Not to exceed 15% of the total sum insured)
Toiletries
Chair(s)
Replac. Cost at Dest.:
EUR
-
Towels, etc.
Curtains/Drapes
Non-Factory Installed Auto Accessories
Clothes Hamper
Sofa
EUR
-
Trash Can
Table(s)
Must be Separately Listed, Valued,
SILVER:
Cabinets, Mirrors
Lamp(s)
and attached if applicable
Hair Dryers
Rug(s)
TOTAL AUTOMOBILE:
EUR
-
Misc.
Desk
GRAND TOTAL:
Bookcase
EUR
-
COLUMN SUB-TOTAL
-
COLUMN SUB-TOTAL
-
COLUMN SUB-
TOTAL
-
*Items valued at over EUR5,000 per item/set must be listed as High Value Items on a separate sheet.
Please insure my shipment for EUR which is the estimated replacement cost at destination of my shipment. By accepting this Valued Inventory List, I am verifying that it is true and authorize Pac Global Insurance Brokerage, Inc. to insure my household goods and personal effects subject to the Terms & Conditions of the Policy.
SIGNATURE DATE