Private Collectibles and Valuables Insurance Proposal Form – Wine Storage 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):

Date of birth:

Location (Situation) Details

Section D – Wine Storage

Name of storage facility:

Address:

State:	Postcode:

Value of Assets

Total Sum Insured: $

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

Locks - How is the hired storage space secured?

Padlocked	Yes ☐	No ☐
Keypad access	Yes ☐	No ☐
Other – please describe	Yes ☐	No ☐

Alarm – Is the hired storage space alarmed?

Entire complex/building only	Yes ☐	No ☐
Individual hired storage space is alarmed	Yes ☐	No ☐

Staff – Are there staff on site?

Business hours only	Yes ☐	No ☐
Business hours plus after-hours access and weekends	Yes ☐	No ☐
24 hours	Yes ☐	No ☐

Access

Does the Proposed Insured have exclusive access to the hired storage space?	Yes ☐	No ☐

If no, who has access to the storage space?

Storage Conditions

Where is the wine stored within this location?

Purpose built cellar (climate controlled)	Yes ☐	No ☐
Wine fridge	Yes ☐	No ☐
Storage racks (climate controlled)	Yes ☐	No ☐
Other (please provide details)	Yes ☐	No ☐

Details of Assets

Please detail Wine and/or Spirits to be insured:

Please make descriptions as detailed as possible.

Description (producer/vineyard/distiller, style of wine/spirit, year of production, bottle size (eg 700ml), bottle no. if available)	Sum Insured
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

If there are more items to be listed, please provide further details in the space provided on page 4 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