Private Collectibles and Valuables Insurance Proposal Form – Additional Location Addendum

Keystone recommends that the proposed Insured keep a record of all information supplied for the purpose of entering into an insurance contract. Please answer all questions in full. If there is insufficient space, please provide further details on a separate sheet. All attached documents form part of this Proposal.

General Details

Proposed Insured Name (list all names, or where applicable, the full name of the superannuation fund as it should be shown in the policy):

Additional Location (Situation) Details

Section A – Additional Private Home of the Insured

Address:

State:	Postcode:

Value of Assets

Jewellery and Valuables (only for items permanently stored at this location – not worn):

(eg. jewellery, watches, coins, banknotes, currency, bullion and precious metals, diamonds and precious stones)

Total Sum Insured: $

Artwork and Collectibles:

(eg. paintings, objets d’art, silverware, tableware, glassware, porcelain, ceramics, pottery, china, sculpture, furniture, books, stamps, wine and spirits, antiques and collectibles of whatsoever nature)

Non-Fragile: $

(this is for artworks and collectibles of any nature that would still have value even if damaged or broken, and that are not jewellery, precious stones, currency, negotiable instruments, or precious metals)

Fragile: $

(this is for artworks and collectibles of any nature that would lose all value if damaged or broken, and that are not jewellery, precious stones, currency, negotiable instruments, or precious metals)

Building Construction

Walls	Brick ☐	Concrete ☐	Stone ☐	Timber ☐	Steel ☐	Other ☐
Roof	Tile ☐	Slate ☐	Concrete ☐	Metal ☐	Other ☐

Fire Protection

Smoke detector	Yes ☐	No ☐
Extinguishers	Yes ☐	No ☐

Security

Is the Situation an apartment?	Yes ☐	No ☐
If yes, is the apartment self-contained?	Yes ☐	No ☐
If yes, is the apartment located on level 4 or above?	Yes ☐	No ☐

Locks

Standard locks on external doors	Yes ☐	No ☐
Deadlocks on external doors	Yes ☐	No ☐
Locks on external windows	Yes ☐	No ☐

Alarm

Local alarm system (bells only and/or alert to mobile phone)	Yes ☐	No ☐
If yes, does the alarm cover all areas containing the insured items?	Yes ☐	No ☐

Monitored alarm system (alert to security service/police)	Yes ☐	No ☐
If yes, does the alarm cover all areas containing the insured items?	Yes ☐	No ☐

Safe(s)

Safe	Yes ☐	No ☐
If yes, does the safe weigh more than 250 kg?	Yes ☐	No ☐
If no, is the safe secured to a solid wall or solid floor?	Yes ☐	No ☐

Occupancy

Will the situation ever be left unattended for more than 60 days at a time?	Yes ☐	No ☐
Will the situation be regularly left unattended at night?	Yes ☐	No ☐

Details of Assets

Please detail any Jewellery and Valuables to be insured:

Please make descriptions as detailed as possible.

Description	Sum Insured
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

If there are more items to be listed, please provide further details in the space provided on page 5 of this Proposal or attach a separate sheet.

Are valuations or purchase receipts not less than three years old available for items worth more than $5,000?	Yes ☐	No ☐
If yes, please provide copies.

Please detail any Artwork and Collectibles to be insured:

Please make descriptions as detailed as possible.

Description (title, artist, year of production, medium, dimensions)	Sum Insured
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

If there are more items to be listed, please provide further details in the space provided on page 5 of this Proposal or attach a separate sheet.

Are valuations or purchase receipts not less than three years old available for items worth more than $5,000?	Yes ☐	No ☐
If yes, please provide copies.

Additional Information