PLATINUM LUMP SUM ENROLMENT FORM

Full Name of Applicant Vikas Gupta

Packing date 24-27th June 2019
Owner Packed No
Professionally packed Yes
Mode of transport Sea
Origin city and country BSD city, Indonesia
Destination city and country Bangalore, India

1) Do not include bank & treasury notes, firearms, furs, jewellery (including
precious metals and stones), money, perishables (e.g. make up, perfumes, food)
plants, securities, stamps, watches or weapons, as these items are excluded from
the Protection Cover. (see exclusions for further details)
2) Do not include more than EUR 10,000 worth of wine/ liquor or more than EUR
100,000 of fine arts
3) Enter the cost of your move if you are covering your shipping costs
4) It is required that this form is signed, dated and returned to Santa Fe prior to
packing.
5) Please ensure that any item or set valued individually at more than EUR 1500 (or
equivalent in other currencies) is listed separately.
The chargeable scale is based on cubic meter (i.e. CBM). One (1) cubic
meter is equivalent to 35.32 cubic feet.
Each cubic meter of goods is given a fixed value at the minimum of EUR
2500 (or equivalent in other currencies). You may declare at a higher value
if required but cannot declare at the value less than EUR 2500/cubic
meter.
Minimum volume is at one (1) cubic meter (or EUR 2500).
Any item or set valued in excess of EUR 1500 (or equivalent in other
currencies) must be separately listed and are in addition to the minimum
EUR 2500 per cubic meter calculation.
Final chargeable scale will be based on the actual measurement of the
shipment after packing and crating has been completed

(A) Total cubic capacity of your shipment High Value Item List
(One cubic meter is equivilant to 35.32cuft) Please list and value any items or sets in
= 50 Cubic meters your shipment worth more than EUR 1500 Value (Euros)

(B) @ EUR 2500 per cubic meter

125000 L shape leather sofa 1800
(i.e. Section a x EUR 2500= Section B)

(C) Plus the total of any items valued in excess of Set (Coffee table, 4 side tables, tv unit, 2
4500
EUR 1500 as listed on this inventory standing units)
75800

(D) Household goods total Samsung LED TV 55 inch 3000

(i.e. section b + section c= section d) 200800

(E) Automobile Sony LCD TV 40 inch 1800

0
(F) Shipping costs
If you wish to insure your shipping costs please Samsung QLED 65 inch TV 5500
enter the cost of your move NA

42 pc. China set 1500

Leather electrical recliner 2400

Electrical treadmill 2500

Decorative Sword 2000

Pictures/Paintings (3) 6500

Chest of drawers 2300

Piano 6700

Decorative set (parrots) 7000

Statue 1500

Bed with 2 side tables 3500

Guest room bed 2500

Book case 2600

Bar unit 3800

Ganesha Sculpture 1800

Wooden trunk 1600

Grand Total Indonesian single piece dining table 11000
(i.e. Section d+ Section e + Section f= Grand Total 276600

Please Indicate the currency you are using to Euro Total High Value items 75800
insure your goods (please enter the total value in section (C)

Declaration of the Proposer

I declare that I have disclosed all material facts and understand that failure to do so could render my enrolment and coverage void. I declare that the amounts stated above
are the full value of the goods at destination. I confirm that I have declared all items that I wish to be covered with all details requested. I have read the conditions stated
overleaf and understand that these shall form the basis of my enrolment in the All Risk Protection Policy.

Signature

Date