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Policy Start Date*
MM slash DD slash YYYY
First Name*
Last Name*
Email*
Phone*
Address Line 1 Address Line 2 City State Zip Code
Is your collection stored at the same address?
- Yes
- No
Alternative Address
Address Line 1 Address Line 2 City State Zip Code

Custom Collection
General Collection
$

(example: art, comics, sport memorabilia, antiques, etc.) Guns and Hunting Accessories:
$
Stamps
$

(example: art, comics, sport memorabilia, antiques, etc.)
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OTHER
Other Collections to insure:

Comics

Art

Sports

AdvertisingCollectibles

AntiqueRadios

AntiqueTools

Dolls

CoinOperatedDevices

Entertainment

Furniture

GlassAndPottery

HuntingAndFishing

LimitedEditionItems

MusicalInstruments

VintageSewing

WesternAmericana

Whiskey

Wine

WritingInstruments

ZippoLighters

Other
types of collections you can insure and
EXCLUSIONS
Exclusions to our coverage:

Government seizure or destruction of property

War and nuclear hazards

Gradual deterioration such as fading, creasing or denting

Nesting, infestation or discharge or release of waste products or secretions by insects, rodents or other animals

Dampness or dryness of atmosphere

Changes in or extremes of temperature other than fire

Fraudulent, dishonest or criminal acts

Voluntary parting with covered property

Loss or damage while being worked on by you or others working on your behalf

Mysterious disappearance

This is not a complete list of exclusions and exclusions can vary by policy.
to the coverage provided.
Do you have gold or platinum coins?
- Yes
- No
Do you have any individual items over $25,000 in value?
- Yes
- No
Approximate value of your collection

Comics

$

Sports

$

Art

$

Dolls

$

Antiques

$

Toys and Action Figures

$

Trading Cards

$

Other

$
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