Henderson Phillips Fine Arts Insurance Arthur J. Gallagher & Co. of New York, Inc.

Thank you for your interest in receiving a fine art / collection proposal of insurance from Henderson Phillips Fine Arts Insurance. Please print this application, complete it and fax to your representatives attention.

AFA ArtSure Fine Arts Insurance Program MUSEUM FINE ARTS APPLICATION
Name Street Address City State Zip Code

Permanent Collection Information Approximate Total Value, including long term loans Collection consists primarily of the following (percentages): Oil on Canvas Works on Paper Sculpture (Fragile) Sculpture (Not Fragile) Other Other

Digital Inventory Records Yes________No_______ How often are records (appraisals or other) updated?_______

Temporary Loan Information Maximum limit per month on premises Limit in transit

Any other location United States and Canada

International

Number of Exhibitions on Premises: Annually_______; Average total value of each exhibition _____________ Is Wall to Wall coverage provided to all lenders Yes _______ No________

Facilities Information Was building originally designed as a museum? If not, please advise original design

Date built

Number of floors

Fire doors between galleries: Yes

No

1627 I Street, NW, Suite 800, Washington DC 20006 P: 202.223.5860 F: 202 223.5866 444 Madison Avenue, 20th FL., New York, NY 10022-6903, P: 212.994.7116 F: 212.994.7058

Henderson Phillips Fine Arts Insurance Arthur J. Gallagher & Co. of New York, Inc.

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Security Central Station Alarm Sprinklered Halon Certified? Certificate No and Date

Are Guards present while museum is open?_____________ How many?___________ Please attach an up-to-date Facilities Report and/or describe security system in detail

Amount of Insurance Desired (Amount should equal the combined Permanent Collection and Temporary Loans premises limits listed on page 1:$ Deductible Transit $ International $

Are you accredited by the American Association of Museums? If not, please list below: (or attach a list) of all staff members handling works of art, including their professional training and experience. Note: Normally volunteers should not be handling art.

Please list the five highest valued items: 1. 2. 3. 4. 5. Shipping Maximum value in any one shipment:______________; Total value of shipments (annually):___________ Who is responsible for packing and shipping: ___________________________________________ Are condition reports completed prior to and upon receipt of each shipment?____________________________________ List shippers/transporters used______________

1627 I Street, NW, Suite 800, Washington DC 20006 P: 202.223.5860 F: 202 223.5866 444 Madison Avenue, 20th FL., New York, NY 10022-6903, P: 212.994.7116 F: 212.994.7058

Henderson Phillips Fine Arts Insurance Arthur J. Gallagher & Co. of New York, Inc.

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Losses Please describe briefly all losses during the past 5 years, whether insured or not. Date Amount Description

Are you presently insured? Yes

No____

Name of company (ies)_______________________________________ Have you had any insurance non-renewed, cancelled, or denied by any insurance company?________________________

APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND I DECLARE THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF ALL OF THE FOREGOING STATEMENTS ARE TRUE; AND THAT THESE STATEMENTS ARE OFFERED AS AN INDUCEMENT TO THE COMPANY TO ISSUE THE POLICY FOR WHICH I AM APPLYING. PROGRAM ELIGIBILITY, COVERAGE AND PREMIUM WILL BE DETERMINED UPON THE UNDERWRITING REVIEW OF THE APPLICATION BY A REPRESENTATIVE OF THE INSURANCE COMPANY.

Insureds Signature:

Date:

Title:

Telephone:

Producers Signature____

Date:

1627 I Street, NW, Suite 800, Washington DC 20006 P: 202.223.5860 F: 202 223.5866 444 Madison Avenue, 20th FL., New York, NY 10022-6903, P: 212.994.7116 F: 212.994.7058