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Insurance Provided by Gemshield/Hallberg Insurance Network

Insurance available for this product.
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Insurance Provided by Gemshield / Hallberg Insurance Network

Insurance premium and fees will be $ for all item(s).

Please complete the following information.

Question	Yes	No
Do you currently have an existing gemshield jewelry policy?(*)
Have you had any previous jewelry losses in the past three years?(*)
Do you play profesional sport or are you in the entertainment industry?(*)
Have you ever been convicted of a felony?(*)
Did you purchase loose stones?(*)

Disclosure Agreement

I understand and acknowledge that incorrect information may make my policy unenforceable and that it can be a criminal or civil crime to knowingly and with intent to mislead, file an insurance application containing any false information or conceal information concerning any material fact. I also understand and acknowledge that for the failure or refusal of any insurance carrier to cover or pay any loss or claim, that I release and discharge Wasserman & Wexler LLC, Sonic Insurance Agency, Hallberg Insurance Network, from any liability due from such failure or refusal.

Personal information about you, including information from a credit or other investigative report, may be collected from persons other than you in connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to determine either your eligibility for insurance or the premium you will be charged. We may use a third party in connection with the request for correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instruction on how to submit a request to us.

to be bound to the terms of the above agreement. Immediate insurance is available per your agreement to the above terms from Hallberg Insurance Network agencies.

I AGREE I DISAGREE (- * - This is required)

Processing and Data Transmission Convenience Fee

The Technology Processing Company is pleased to provide you with the technology that immediately transmits your information, including the jewelry data, to the insurance company. This is a unique convenience solution that enables your new jewelry purchase to be fully insured during your online purchase. The Technology Processing Company charges a one-time applicable fee for processing this service and is not charged on renewals. I have full knowledge and consent to being charged the above applicable processing fees for data transmission and storage by the Technology Processing Company.

By checking the checkbox, I certify that I have read and agree with the above statement and agree to accept the convenience processing fees charged by the Technology Processing Company on my credit card.

I AGREE

I DISAGREE

(- * - This is required)

GemShield/IJN is a jewelry insurance replacement program, underwritten by Hanover Insurance Company. If you incur a loss, your jewelry will be replaced with a piece of like kind and quality from the participating jeweler who originally sold you the item. It is a worldwide insurance policy that includes coverage for sudden and accidental damage and mysterious disappearance. You will receive your insurance premium receipt by email and the policy will follow.
Your Jeweler is not a licensed agent of Gemshield and does not sell insurance.

Result

Congratulation you are qualified for this insurance!!

Product Price
Insurance Premium and Fees (combined total)
Include Quality Assurance Document	$.00


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