Private Collectibles and Valuables Insurance Proposal Form – Additional Bank or Vault 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 B – Additional Bank or Vault

Name of Bank/Vault Facility:

Address:

State:	Postcode:

Value of Assets

Jewellery and Valuables:

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

Total Sum Insured: $

Maximum amount worn at any one time: $

(this is the maximum combined value the proposed insured would like to wear at any point in time.)

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)

Security

Does the bank or safety deposit vault have dual control procedures?	Yes ☐	No ☐

Outside Bank/Vault Cover

Is cover required outside the bank/safety deposit vault in the short term?	Yes ☐	No ☐
If yes: List items to be removed: $ for days $ for days $ for days Reason/s for removing the items from the bank/vault:
Valuation	Yes ☐	No ☐
Repair/cleaning	Yes ☐	No ☐
Wearing for special occasion	Yes ☐	No ☐
Exhibition (please provide details)	Yes ☐	No ☐
Other reason (please provide details)	Yes ☐	No ☐
Is transit cover required while outside the bank/vault?	Yes ☐	No ☐
Personal conveyance	Yes ☐	No ☐
Australia Post	Yes ☐	No ☐
Commercial Courier	Yes ☐	No ☐
How many times per year will transit be required? Address where item/s will be located when away from the bank/vault: State: Postcode: Security of this location (alarm, locks on doors/windows, CCTV, safe):

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