Total Dollar Insurance

Fine String Instrument Insurance

Please complete this form so we can prepare a quote and contact you with the details.
PERSONAL INFORMATION
How Did You Learn of Total Dollar?
Name of Reference?:
Name To Be Insured: *
Address: *
City: *
State or Province: *
Zip or Postal Code: *
Country: * USA
Other
Home Phone Number:
Daytime Phone Number: *
Mobile Number:
Email Address: *
CURRENCY OF SCHEDULE
Currency of Schedule * USD
CAD
EUR
SCHEDULE OF ITEMS TO BE INSURED
  Description of items to be insured Value Appraisal Date ?
1.
2.
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4.
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6.
7.
8.
CURRENT INSURANCE INFORMATION
Current Insurer:
Expiration Date:
Losses In Last 5 Years: If "None" Please say so, otherwise describe amount,date and cause of loss *
ADDITIONAL INFORMATION
Your Occupation:
Name of Employer or if a Student, Name of School You Are Attending? *
Your Age *
Who Plays The Instrument(s)? * Self
Son
Daughter
Other
If Other, What is the Relationship?
Name Of Musician If Other Than Self?
If Son or Daughter, What Is His/Her Birthdate?
Location of Instrument(s) If Other Than Address Above (City, State):
If in CA, any Brush Fire Exposure? Yes  No
What Is The Fire Protection? * None
Smoke Detector(s)
Fire Extinguisher
Sprinkler System ?
What is the Security Where the Instrument(s) Is (Are) Stored? * 24 Doorman
Security System
Standard Doorlocks
Other ?
If Security System, Please Check ALL That Apply: Central Station (monitored) Burglar Alarm
Central Station (monitored) Fire Alarm
Building Monitored Fire Alarm
Building Monitored CCTV (hallways)
Other ?
Where in the Residence Is the Collection Kept?
Do You Have A Vault Or Safe?
Additional Comments
* = Required Field
Thank you for your submission. You will be contacted shortly by a representative of Total Dollar.