Collector Insurance Program

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Collectors Insurance Enrollment Application

Please complete the following application
Print TWO copies of the completed application.
Sign one copy of the completed application.
Send the signed copy, along with payment or credit card information to:
     Association Insurance Administrators
     P.O. Box 4389
     Davidson, NC 28036

Identification

Name:

E-Mail Address:

Mailing Address:

Daytime Phone:

Evening Phone:

Payment Method:

VISA MasterCard Check/Money Order

Type and Amount of Coverage Requested

Are you a dealer?

Yes No

If 'Yes', is coverage being requested for any property that is
being held for sale?
Yes No

Amount of Blanket Coverage :

This is the total amount of coverage that you want for UNSCHEDULED items under $2,500.00 of value.

Scheduled Items:

Please list below any items that you wish to cover that have a value of $2,500.00 or more per item. In addition, we require that you provide photos of each scheduled item for which you are requesting coverage.

For each item declared, please describe it, including any distinguishing characteristics, registry/serial numbers, general condition, color, size, etc. and its value.

Item #1:		Value:
Item #2:		Value:
Item #3:		Value:
Item #4:		Value:
Item #5:		Value:
Item #6:		Value:

Inventory Information

Estimate Percentage of Inventory by Category

% Advertising % Art % Autographs % Books % China & Ceramics % Coins % Crafts % Dolls % Ephemera % Furniture % Glass % Guns (New) % Guns (Old) % Other		% Jewelry (Costume) % Jewelry (Fine) % Kitchenware % Movie/TV Memorabilia % Posters % Pottery % Records/CD's % Reproductions/New Merchandise % Sports Memorabilia % Stamps % Textiles % Toys % Trading Cards % Other
*Please include general photos of your collection.*

Record Keeping

Do you keep inventory records?
	Yes No If 'Yes' , what type of record? Written Computer Receipts Photographs

Do you take a physical inventory?
	Yes No If 'Yes' , how often? Monthly Quarterly Occasionally Never

Where do you keep your inventory records?


Do you keep a duplicate copy of your inventory record?
	Yes No If 'Yes' , where is the duplicate kept? Off Premise On Premise

How long have you been a collector?

Inventory Location

Stored at your home...

Inventory Value

Address

Type of Construction

Frame		Masonry		Steel
Other:

Security

Central Alarm System		Deadbolts		Safe		Smoke Alarms
Other:

Current Insured Value

Insurance Company

Stored at your office...

Inventory Value

Address

Type of Construction

Frame		Masonry		Steel
Other:

Security

Bars		Central Alarm System		Deadbolts		Safe		Smoke Alarms
Other:

Stored at your warehouse or other facility...

Inventory Value

Address

Describe

Type of Construction

Frame		Masonry		Steel
Other:

Security

Alarmed		Fenced		Gated		Locked		24Hr Guard
Other:

Stored at your bank...

Inventory Value

Stored at another location...

Inventory Value

Describe

Insurance Coverage History

Have you had prior insurance?

Yes No
If 'Yes' , what is the name of the company? (Not the Agent or Agency.)

Have you ever been cancelled or non-renewed by your insurance company?

Yes No
If 'Yes' , please provide the details:

Have you ever declared bankruptcy?

Yes No
If 'Yes' , when?

Have you ever had a loss?

Yes No
If 'Yes', how much was your loss?:

If 'Yes', please provide the details:

Finalize Application

Once you have completed all of the information on this form, click on the 'Prepare Application' button below. This will take all of the information that you supplied and create a completed application that you may print and send in with your payment.

Do not click the button more than 1 time.