Name of Insured:

Name of Additional Insured/Loss Payee:

Address of Certificate Holder Loss Payee:

Dates Required:

Transit insurance required? YesNo
Method of transit:

Transit company:

Who is packing artwork?

Duration of transit:

Waver of subrogation required? YesNo

Information About Artwork

Artist:

Name of work:

Value of work:

Dimensions:

Description of work:

Contact Info

First Name*:

Last Name*:

Email*:

Phone*: