Private Collectors Insurance

 Personal Information

* Indicates a required field.
*Name: 
*Mailing Address:  
*City:  
*State:  
  *Zip:
*Phone (Home):  
FAX:  
*Phone (Business):  
*Total Blanket Amount of Insurance:  
 (100% value of collection)

 Inventory Information

*What percentage of your collection is Numismatics?:  
*What percentage of your collection is in Currency/Script?:  
*What percentage of your collection is in Clocks?:  
*What percentage of your collection is in Watches?:  
*What percentage of your collection is in other items?:  
*Please describe your collection to include
general quality and condition:

 General Information

*Is your entire collection kept at home?:
(If no explain)
Yes    No  
*Is your collection ever on exhibit?:
(If yes explain)
Yes    No  
*Describe Residence:
If other explain:
Single Home    Condo/Apartment    Other  
*Who is your homeowner's insurance carrier?:  
*What is the insured value of your home?:  
*Does your home have (check all that apply):
Smoke Detectors: 
Yes    No  
Dead Bolt Locks: 
Yes    No  
Burglary Alarm System: 
Yes    No  
   If yes, is it to a Central Station?   Yes    No  
Safe: 
Yes    No  
   If yes it's Type:
   UL Rating:
   Is Safe wired to a Central Station?   Yes    No  
*What is the distance to the nearest:
*Fire Hydrant: 
*Fire Department: 
*Police Station: 
*During the past 5 years have you ever had a loss?:
Yes    No  
If yes, please explain each loss:  
*Deductible amount ($250 minimum):  
Please include a list of each item with a value over $10,000.
Include any distinguishing features, condition, color, size, etc.

Item 1

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 2

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 3

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 4

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 5

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 6

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 7

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 8

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 9

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 

Item 10

Manufacturer/Year Produced: 
Manufacturer Number or Serial Number: 
Description: 
Value: 
To be eligible for this program, you must be a member of the North American Collectibles Association. Collector membership fees are $135 annually.

I hereby authorize my alarm company to release any details regarding the qualifications of my alarm system to the North American Collectibles Association for the purpose of obtaining premises insurance. Signing this application and declaration does not bind the applicant or the insurance company to complete the insurance, but it is agreed that this application and declaration shall constitute a warranty should a policy be issued. I have read the above and agree that to the best of my knowledge and belief it represents a true and complete statement.

Requested Effective Date:  
*Applicant Signature:  
Application Date:
03/27/2023