Are you solely a collector?		Yes No
(a collector does not take booths/tables at shows, have a personal website selling material or derive their main income from the sale of material)
If your answer is No, please telephone 1 888 277-6494 for assistance.
Personal Details:
Family Name:
First Name:
Initial:		ANA Membership Number:
Mailing Address:			Zip Code:
Street Address (if different):
Home Phone:
Work Phone:
Mobile Phone:
Email:
How many years have your been collecting?			Are you under 21 years old? Yes No

Your Collection:

Market Value of items to be insured:	$
Nature of your collection:(e.g. paper money, ancient coins, US graded, etc.)
What percentage is Bullions coins?	%
Is a complete record of your collection maintained? Yes No
If No, please state how the exact amount of loss could be ascertained:
Have you acquired more than 50% of your collection through inheritance, gift or in a single purchase? Yes No
If Yes, please provide details:

The Location:

If your storage location is different to the address above please provide the storage address here:
Name and address of Bank/SDV where your collection will be:

Insurance Cover Required:

Please select ONE of the options below.

Vault Policy	This policy provides cover in a bank or safe deposit vault (SDV) only.
Bronze Policy	This policy provides cover at home only.
Silver Policy	This policy provides cover at home and/or in a bank/SDV and allows you to hand carry $50,000 (or your policy limit if less) between the bank and home only.
Gold Policy	This policy provides cover at home and/or in a bank/SDV and allows you to carry $50,000 (or your policy limit if less) anywhere in USA/Canada plus mailing by registered or insured USP Services within USA/Canada.
Platinum Policy	This policy is tailor made for collectors requiring a sum insured above $500,000.
When do you want the above selected insurance to start? (Please note that no insurance will be arranged without your written acceptance of a quotation).

Security Measures:

Fill in this section only if you have selected a Bronze, Silver, Gold or Platinum Policy Above.

Is this a private residence, self-contained and exclusively under your control?		Yes No
Is it constructed of brick/stone/concrete?		Yes No
If the answer is No please provide details:
Do you have mortise deadlocks or other similar key operated security fitted to all external doors?		Yes No
If the answer is No please provide details:
Do you have a safe?		Yes No
If there is No safe, do you keep your collection in a locked cabinet or similar?		Yes No
Do you have an alarm system?		Yes No
If Yes, is it a central station alarm (please provide details):
Please provide detail of any other security protection:

History:

Have you suffered any loss in the last five years, whether insured or not?		Yes No
If Yes, please provide full details:
Has any company declined to accept, cancelled or refused to provide insurance for you?		Yes No
If Yes, please provide full details:

Declaration:

To the best of my knowledge and belief the information provided in connection with this application, is true and I have not withheld any material facts. I understand that any non-disclosure or misrepresentation of a material fact may entitle insurers to void the insurance. ( A material fact is one likely to influence acceptance or assessment of this proposal by the Underwriters: if you are in doubt as to what constitutes a material fact you should consult Hugh Wood Inc.) I understand that the submission of this application form does not bind me to complete the insurance but agree that, should a contract of insurance be concluded, this application form and the statements made herein shall form the basis of the contract.