Welcome to GemShield Jewelry Insurance

Fill out form and receive a quote! Or click here for a printable application you can mail. (Coverage is not automatic. Contact us at 1-866-207-9428 for a participating jeweler)

Date -- mm/dd/yy

Please mail my certificate to:
Purchaser
Person who will posses the jewelry

Purchaser

First Name

Last Name

Middle Initial

Street Address

City

State/Province

Zip/Postal Code

Country

Work Phone

E-mail

Person Possessing Jewelry

First Name

Last Name

Middle Initial

Street Address

City

State/Province

Zip/Postal Code

Country

Work Phone

E-mail

Please contact us at 1-866-207-9428 for your state rate and quote.

Do you have an existing policy or certificate?

Yes No
If yes, Company Insured With:

Do you have a central station alarm at your residence? Yes No

Do you have a safe at your residence?
Yes No

Have you had any previous losses?
Yes No

If yes, explain below:

Have you ever been convicted of a felony?
Yes No

Item

Color

Clarity

Cut

Carat Weight

Mounting

Jeweler's Information

Name

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

FAX

E-mail

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