WRIDGWAYS

The Removalists.
A Division of Wridgways Limited ABN 66 065 419 712

Application for transit insurance

This is not a confirmation of insurance.

WRIDGWAYS
The Worldwide Movers.
A Division of Wridgways Limited ABN 66 065 419 712

Name Origin Address:

Najum Zaidi 7 Bentley Street, Rooty Hill, NSW 2766 Periods Covered x Transit Storage Risks Covered x Full Cover

Destination Address:

Mt. Isa, Qld Method of Transport x Land Sea

Select your required cover:

Basis of Settlement x Replacement Cost

Itemise and value your goods: Use the list below to itemise the value of your goods. When estimating the value of your goods: If you have selected Replacement Cost cover, ensure you estimate the cost of new goods of a similar type at the point of destination. If you have selected Market Value cover, estimate the amount which your goods would be worth. Important: Items not declared and valued are not insured. Remember that if you underestimate the value by less than 80%, the amount of your claim may be reduced.

Bedrooms

No Declared Value

Lounge

No Declared Value

Kitchen

No

Declared Value

Dining

No Declared Value

Outside

No Declared Value

Sundries (cont.,)

No Declared Value

Baby Bath Bassinet & Stand Bed Queen & M Bed Single & M Bed Folding Bedside Table Bookshelf Bouncinette Box or Chest Carpet/Lino Chairs/Stools Change Table Chest of Drawers Cot Cupboard Desk Divan Dressing Table Headboard Lowboy Mirrors/Lamps Lowchair Pram/Stroller Wardrobe Blanket/Linen Pictures/Paintings Clothes-Men's Clothes-Women's Clothes-Children's Radio/TV's Toys/Books

Bar $200.00 Bean Bag $2,400.00 Mirror $1,400.00 Bookcase Bookshelf $400.00 Carpet Rugs Chair Arm Chair Other $500.00 China Cabinet Coffee Table Desk $600.00 Divan Heater Lounge Suite Occ.. Table Organ $600.00 Piano Standard Lamp Stereo System $200.00 Stereo Cabinet Stereo Speakers Stool TV Video $250.00 Wall Unit $800.00 Wine Rack $800.00 Pictures/Paintings Crockery/China $4,000.00 Clocks $700.00 Books Radio Records/CD's Futon

Cabinet Dishwasher Dresser Freezer Fridge High Chair Kitchen Chairs Kitchen Table Microwave Stool Tidy Crockery/China Pots/Pans Electrical Appli Food Plasticware Bowls/Trays $500.00 $1,000.00

Air Cooler/Fan Bookshelf Buffet/Sideboard Carpet $1,500.00 Crystal Cabinet Dining Chairs $400.00 Dining Table $400.00 Other Chairs $1,500.00 What Not $150.00 Linen China/Glasses $2,000.00 Cutlery Spirits/Wine Pictures/Paintings

BBQ Bicycle/Trike Compost Bin Garden Tools Garden Hose Kennel T/Tennis Ladder Mower Swing (Dism) Playgym Pool (Dism) Tools/Barrow Trampoline Workbench Outdoor Furniture

Golf Bag/buggy Timber Knit Machine Outboard Motor Polisher Saw Horse Sewing Machine Sewing Table Skis Fishing Rods Suitcase/Trunks Surf Board Table Tent Camping Gear Vacuum Cleaner Welder Typewriter Sundries Clocks Computer Equip Musical Inst. Photo Equip Film/Video Tapes Audio/Tapes Picts/Paints Other

Hall Dropside Table Family Billiard Table Bar Bookcase/Shelf Carpet Rugs Chair Desk $600.00 Divan Table Standard Lamp Computer Video TV Pictures/Paintings Laundry Brooms etc Clothes Drier Cupboard Ironing Board Table Washing Machine $700.00
Containers packed by owners Please List

Glory Box Grandfather Clock Stand Hall Table Phone Table Pictures/Paintings

Beach Umbrella Cupboard Dolls House Filing Cabinet Fish Tank/Stand

Sub Total

$12,850.00 Sub Total

$600.00 Sub Total

$8,150.00 Sub Total

$0.00 Sub Total

$0.00 Sub Total

$0.00

(Attach a separate list if more space is required)

Total value to be insured (inclusive of GST)

$21,600.00

Valuables: Please list and estimate the value of any antique, curio, plate, precious object, work of art, medal, coin, stamp, collection of items, fur, piece of precision equipment or professionally packed carton by the removal company whose value exceeds $1000.00 in the table below. Attach a detailed inventory if you need more space. SPECIFIED ITEM VALUE SPECIFIED ITEM VALUE

Declaration: I declare that the above values are correct to the best of my knowledge and that I have informed the Removal Company about anything which could affect the risk. I have received a copy of the Financial Services Guide and the Product Disclosure Statement. Signature: Date:

Wridgways Limited is an authorised representative of Aldridge & Street, a Division of Cowden (VIC) Pty Ltd which holds Australian Financial Services Licence No 245658