Certificate of Insurance 
ISSUED UNDER OPEN POLICY 534 BY 
ORIENT INSURANCE COMPANY 
No.. 
11753 
3!u nmsiftfratimi of tljr luorrantipa hrrritt contained. 
Insurance is granted tc 
whose residence address 
(hereinafter called the “Assured”) 
JL 
against loss or damage m amount not exceeding . 0 . .(/.. .Dollars (United States Currency) to the personal effects and the 
property as hereinbelow scheduled, directly caused by one or more of the perils insured against; subject in all respects to the terms 
and conditions in Open Policy 534 issued by the ORIENT INSURANCE COMPANY OF HARTFORD, CONNECTICUT to the 
American Express Company for the account of the Assured above named. 
I. 
SCHEDULE OF PROPERTY COVERED 
(a) Wearing Apparel (except while being worn), Toilet Articles, Clocks, Trunks, Hat Boxes, Suit 
Cases and other baggage containers, Photographic Apparatus and supplies, Musical and 
Scientific Instruments, Sportsman’s Implements ( excluding Bicycles, Motorcycles, Canoes, 
other conveyances or their appurtenances), Field Glasses, Toys and Games, Printed Books 
and Music, Bedding, Linens, Laces and Embroideries, Silks, Rugs, Silverware and 
Tableware, Etchings and Engravings, Art Objects and curios, portable typewiters and 
stationery supplies and all other similar property for personal apparel or household use 
now owned or which may be acquired during the term of this insurance: 
(b) Jewelry, (including watches) as listed. No article of jewelry shall he covered unless described in 
the following list with a separate value for each article and for not exceeding 30% of the total 
value insured under this certificate unless such excess is accepted by special agreement and 
an additional premium paid as required: 
Full Value and 
Limit of Coverage 
qj eo 
• 8*5 
S'o* 
<41 
^ £ 
i! 
© •«*> 
© 
'is £ 
Tj <41 
•<>> 
<41 
„ • © 
o © 
^ >0 
O 8 
(c) 
Values 
. . $ 
Furs (except while being worn) as listed: only articles consisting entirely or principally of fur 
should be specifically listed. Fur trimmed garments should be included under section (a) as 
wearing apparel . 
Values 
. $ . 
Total amount of insurance evidenced by this Certificate 
$■ 
0 .0.0 ...- 
— 
r/ter- 
EXCLUSIONS. This insurance does not cover canes, umbrellas, parasols, pens, pencils, eyeglasses, salesman’s samples 
chandise for sale or exhibition, theatrical wardrobe, moneys, documents, securities, stamps, evidences of debt or other financial papers. 
II. This insurance extends to and covers articles now owned or which may be acquired during the term of this insurance bv anv 
member of the Assured s immediate family, or any personal servant, if such articles are included in the schedule and if such person 
or persons are named herein. p v 1 
V RM °' F INSURANCE_The insurance evidenced by this certificate shall not commence before the. v .' / day of 
.19 3# nor continue beyond the.. f7 .. .day of sjT*/. . .l^Ait Noon, standard time. 
IV./ TERRITORIAL COVERAGE—This insurance shall not at ariy time, nor under any circumstances attach to or cover the 
said property or any part thereof, while m a permanent residence of the assured (temporary residence in hotel, club or sim^ar 
budding not considered a permanent residence) or while in storage not incidental to travel but with these ex<9ptions and exclusions 
shad cover the property wherever it may be within, and/or in transit between places in Zone... a<3 
defined, and not elsewhere, to wit:— f ^ . neremairer 
Zone A—United States of America, its Territories and Possessions; Dominion of Canada; Bermuda; and the West Indies. 
Zone B—All States, Countries, Colonies or Principalities the World oyer. 
sf C* 
Premium 
Y. 
7 
rz> 
V. PREMIUM—Insured value. . .m. .Rate.../.'! 
, , ,T his Certificate of Insurance shall not be effective unless countersigned on behalf of the ORIENT INSURANCE COMPANY 
and delivered by a duly authorized representative of the American Express Company, nor until accepted by the Assured. 
# i 
Dated at... * 
Countersigned by AMERICAN EXPRESS COMPANY 
the. 
LUr£ 
Authorized Representative 
ORIENT INSURANCE COMPANY. 
Assured 
President 
I accept the insurance evidenced by this certificate under the terms and conditions of Policy 534 issued to the American 
Express Company, and hereby warrant and declare that the sums stated as limits in the schedule of property covered represent as 
near|y as I can estimate, the full value of all personal effects and property, now owned or which may be acquired du-m’g the term of 
this insurance. The persons whose personal effects and property are included and covered by this insurance are:— ’ 
Names 
Relationship to Assured 
Form D3 
Signature of (or for) Assured. X- 
% 
BE SURE TO READ CONDITIONS ON REVERSE SIDE 
