All Risk Form

Owner of Property (herein called Insured):*

Address*

City*

State*

Zip*

Certificate Date:*

Choose Bill of Lading # and/or Warehouse Receipt #:*

Bill of Lading #:*

Effective Date:*

Warehouse Receipt #:

Effective Date:*

Mover Name:*

Mover’s Email:*

Property Insured:

Policy Number:*

Description of Property:*

Premium: $

Amount of Insurance (100% of value of property):* $ Actual Cash ValueReplacement Cost

Choose While in Transit From and/or While in Transit To:

In TransitIn Storage

While in transit from¹:*

While in transit to:*

Permanently stored at²:*

Dollar amount per month of value: $

¹ If either “While in transit from” or “While in transit to” fields are filled in, then both are required information.
² If “Permanently stored at” field is filled in, then the “in transit” fields aren’t required.

REQUIRED: I have read the Terms & Conditions *

Please leave this field empty.

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All Risk Form

Choose Bill of Lading # and/or Warehouse Receipt #:*

Property Insured:

Choose While in Transit From and/or While in Transit To: