ible for its content.
Living Room
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date

Personal Property Inventory
Name:
Address:
City, State, ZIP Phone
Number: Emergency
Number:
Policy Number(s)
Policyholder Information
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________


Agent's Name:
Office Address:
Phone Number:
Emergency Number:
Fax Number
:
Alfa Alliance Insurance Agent Information
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

Living Room
Item

Purchase Year

Description/Brand

Model Number

Quantity

Purchase Price
Sofas
Chairs
Tables
Lamps
Window treatments
Clocks
Rugs/Pads
Desks
Books
Book cases
Musical instruments
Ornaments
Telephone
Pictures/Artwork
Television
Stereo
Equipment
VCR/DVD
CDs, DVDs, tapes
Phone equipment
Collectibles
Subtotal $_____________
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date
Family/Recreation Room
Item
Purchase Year Description/Brand
Model Number
Quantity
Purchase Price
Sofas
Chairs
Tables
Lamps
Window treatments
Clocks
Rugs/Pads
Desks
Books
Book cases
Telephone
Pictures/Artwork
Television
Stereo
VCR/DVD
CDs, DVDs, tapes
Home theater equip.
Collectibles
Toys
Game tables
Computer
Scanner/Printer
Video Games
Subtotal $_____________
Dining Room
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Table
Chairs
Buffet table
China cabinet
Fine china
Holiday china
Glassware/Crystal
Silverware
Serving pieces
Lamps
Window treatments
Clocks
Rugs/Pads
Napkins/linens
Pictures/Artwork
Subtotal $_____________
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date
Kitchen
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Refrigerator
Dishwasher
Stove/oven
Microwave
Compactor
Table
Chairs
Pots/pans
Dishes
Silverware
Utensils
Glassware
Food/Supplies
Blender
Food processor
Mixer
Coffee maker
Toaster oven
Radio
Telephone
Television
Window treatments
Collectibles
Utility Cart/stands
Other appliances
Pictures/artwork
Subtotal $_____________
Hallways/Entryways
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Rugs/pads
Tables
Window treatments
Pictures/artwork
Mirrors
Chairs
Lamps
Coat racks
Collectibles
Subtotal $_____________
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date

Bedroom 1
Item
Bedroom
Description/Brand
Purchase Year
Quantity
Purchase Price
Beds
Bedding
Mattresses
Box springs
Pillows
Dressers
Night stands
Chest of drawers
Armoire
Lamps
Window treatments
Clocks
Rugs/pads
Pictures/artwork
Mirrors
Television
Telephone
Radio
Collectibles
Subtotal $_____________
Bedroom 2
Item
Bedroom
Description/Brand
Purchase Year
Quantity
Purchase Price
Beds
Bedding
Mattresses
Box springs
Pillows
Dressers
Night stands
Chest of drawers
Armoire
Lamps
Window treatments
Clocks
Rugs/pads
Pictures/artwork
Mirrors
Television
Telephone
Radio
Collectibles
Subtotal $_____________
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date

Bedroom 3
Item
Bedroom
Description/Brand
Purchase Year
Quantity
Purchase Price
Beds
Bedding
Mattresses
Box springs
Pillows
Dressers
Night stands
Chest of drawers
Armoire
Lamps
Window treatments
Clocks
Rugs/pads
Pictures/artwork
Mirrors
Television
Telephone
Radio
Collectibles
Subtotal $_____________
Bedroom 4
Item
Bedroom
Description/Brand
Purchase Year
Quantity
Purchase Price
Beds
Bedding
Mattresses
Box springs
Pillows
Dressers
Night stands
Chest of drawers
Armoire
Lamps
Window treatments
Clocks
Rugs/pads
Pictures/artwork
Mirrors
Television
Telephone
Radio
Collectibles
Subtotal $_____________
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date

Sunroom/Porch/Patio/Deck
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Chairs
Tables
Cooking equipment
Window treatments
Rugs/pads
Lamps
Lighting
Fans
Collectibles
Subtotal $_____________
Office/Den/Study
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Sofas
Tables
Chairs
Bookcases
Desk
Computer
Scanner/printer
Books
Bookcases
Rugs/pads
Lamps
Window treatments
Pictures/artwork
Television
VCR/DVD
Telephone
Radio
Clock
Collectibles
Subtotal $_____________
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date

Bathroom(s)
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Clothes hampers
Towels
Linens
Medicine Cabinet
Rugs/Pads
Shower Curtain
Scale
Mirrors
Window treatments
Pictures/Artwork
Appliances
Subtotal $_____________
Attic/Basement/Garage
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Clothes washer
Clothes dryer
Freezer
Freezer contents
Lawn mower
Power tools
Garden tools
Workbench
Decorations
Hand tools
Subtotal $_____________
Fraud Warning! It is a crime to knowingly provide False, Incomplete, or Misleading
Information to an insurance company for the purpose of defrauding the Company.
Penalties include Imprisonment, Fines, and Denial of Benefits.
______________________________________________ ___/___/____
I certify these are true and accurate descriptions and valuations.
Date

Personal Items-Women
Item
Purchased Year
Description/Brand
Model Number
Quantity
Purchase Price
Jewelry
Watches
Suits
Dresses
Coats and jackets
Furs
Handbags
Shoes
Subtotal $_____________
Personal Items- Men
Item
Purchase Year
Description/Brand
Model Number
Quantity
Purchase Price
Jewelry
Watches
Shirts
Slacks
Suits
Neckties/belts
Coats and jackets
Shoes
Subtotal $_____________
Miscellaneous
Item
Purchase Year
Description/Brand
Model Number
Quantity
Pu