DATE (MM/DD/YYYY)

JEWELRY INSURANCE APPRAISAL--SINGLE ITEM

CLIENT'S NAME AND ADDRESS

DESCRIPTION OF ARTICLE(S)
CLASS CODE # CODE DESCRIPTION EST REPLACEMENT VALUE

ITEM OF $
Mounting:

Karatage or % Color Metal type Trademark Workmanship Gender Item Type Size MM Weight
(Mfg & Style#) (Ladies/Mens) (dwt, grm)
Stone(s): (each stone(s) grouping)

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

OPTIONAL DESCRIPTION

Color Photograph Attached

Item Sales Receipt Attached
SIGNATURES
The values set forth herein are an estimate of the current replacement cost at which the appraised jewelry may be purchased in a retail jewelry store and reflects the
price at which the appraised or similar jewelry may be purchased at this store (unless stated otherwise). Because jewelry appraisal and evaluation is not a pure science
and therefore subjective, estimates of replacement value may vary from one appraiser to another and such a variance does not necessarily constitute error on the part
of the appraiser.
This appraisal is given to the customer named above and shall in effect provide customer and their insurer the terms and conditions printed on the reverse side of this
appraisal. The provisions of this appraisal shall inure to the benefit of the named customer's insurance company to the same extent that they would the customer
named herein.

Appraiser Signature: Title: Date:

Print/Type Name: PAGE OF

JISO 78 v.1/2013 (formerly ACORD 78) (Incl material copyrighted by JCRS, Jewelry Underwriting & Claim Mitigation) © JISO 2005-2013
CREDENTIALS
Appraiser certifies the following: He/she is a qualified gemologist holding one of the following credentials: GG from the Gemological Institute of America (GIA),
FGA+ from the Gemmological Association of Great Britain (GEM-A), or an equivalent degree as determined through an equivalency exam administered by GEM-A, and
has successfully completed formal classroom insurance training in jewelry. One such course is the Certified Insurance Appraiser (CIA) Jewelry training course
of the Jewelry Insurance Appraisal Institute, Oakland, CA.

DEFINITION OF JEWELRY INSURANCE APPRAISAL

A written, detailed, description of an item of jewelry adequately describing all characteristics, including weights, grades, and measurements usual to the item
and its component parts, sufficient to determine the actual cash value (replacement cost less depreciation) at time of loss and state a value equal to a price
reasonable for consumer replacement in his/her market place at time of appraisal.

PURPOSE
The purpose of this appraisal is to: 1) Describe the item in such detail as to adequately identify it from other similar types of jewelry, 2) verify the condition (and
existence) of same, and 3) assign a reasonable value for the item as of the date appraised and at a price reasonable for consumer replacement in the insured's
marketplace and not exceeding the price paid, if appraised at time of sale, within 90 days of sale, (unless noted otherwise with explanation fully detailing the
valuation immediately following the item's description and value).

DESCRIPTIONS
At a minimum this appraisal shall provide the following item descriptions where applicable:
Mounting: karatage/purity and color of metal type, trademark and/or hallmark, workmanship, item type, size and/or millimeter and weight in grams or pennyweight.
Stone(s): number of stones, how set, shape and type, GIA grading (including cutting information, MM x MM x MM x MM, color, clarity), total and average weight.
A cutting grade and all necessary stone percentages and angles are stated.
If Jadeite Jade include: texture, transparency, and polish;
If Opal include: potch % play of colors involved, intensity, pattern, and background color;
If Pearl include: cultured or natural, freshwater or saltwater, origin, shape, color and overtone, luster, nacre, blemish, number of pearls and millimeter dimensions and
weight, and clasp information (see mounting and stone requirements);
If Watch include: manufacture, style number, serial number, type, movement and number of jewels (if applicable), features and options; case information
(manufacture, style and serial number); strap/bracelet information (manufacture and style number); bezel and dial information.

GEM LAB & TESTING

The appraiser certifies that this appraisal was performed in a lab equipped with the gemological instrumentation necessary for a thorough and complete appraisal of
the item(s) being appraised. Such instrumentation includes but is not limited to the following equipment: binocular 10x microscope with dark field illuminator,
DiamondLite or comparable equipment, dichroscope, fiber optic lighting, filters and lenses, leverage gauge, millimeter gauge, optical measuring device, calipers, ruler,
long and short wave ultraviolet lamp, master set of five color-graded master diamonds certified by the GIA Gem Trade Laboratory, master set of colored stones or color
communication system, metal testing acids and gold tip needles, penlight, photographic equipment, polariscope with interference figure sphere or lens, refractometer,
scale that gives weights in carats, grams, and/or pennyweight to .001, spectroscope, and dual tester measuring thermal and electro-conductivity.

APPRAISER'S WARRANTY
All items appraised herein have been personally inspected by the appraiser so stated and are in good condition (unless stated otherwise) as of the appraisal date.
Appraiser further warrants that all appraised items herein have been thoroughly and completely tested within the limitations of a GEM LAB as described above and:
1. Diamond and colored gemstone grading is exclusively that of the Gemological Institute of America ("GIA").
2. Metals have been tested by electronic or acid streak test.
3. Gemstones are natural and not synthetic (unless otherwise stated).
4. Gemstones are assumed treated by normal means as stated in The Gemstone Enhancement Manual as "ALWAYS" or "USUALLY". Gemstones treated
by means other than "ALWAYS" or "USUALLY" are so stated.
5. Watches, watch parts and accessories, including but not limited to bands, cases, bezels, dials, and attachments, are genuine parts supplied by the
original vendor or manufacturer of the watch concerned (unless otherwise stated).
6. This appraisal's fee, if any, was not based on the item(s) value.
7. It is also agreed that the Gemological Institute of America (GIA) shall be the final referee in any and all
disputes concerning grading of gemstones. CLARITY
COLOR GIA AGS
CUT NEW
GIA OLD Flaw- Flawless
AGS AGS less / 0 * Internally Flawless (Minor
The CUTTING GRADE of a diamond is deter- 0 D 0 IF * defects of finish are not shown.)
mined by analyzing the proportions and sym- 0.5 E Colorless
metry through the use of instrumented and/or 1 WS1 1
visual techniques and applying deductions 1.0 F Inclusions are difficult to locate
2 Stones in these grades will
for departures from the standards of param- 1.5 G or see under 10x magnification.
"face up" colorless (i.e., slight WS2
eters for table diameter, crown angle, girdle 2
2.0 H 3 traces of color will not be
thickness, pavilion depth, cutlet size and/or apparent in mounted stones to
centering, roundness and finish. 2.5 I 4 other than the trained eye).
VS 1 3
3.0 J 5 Small stones in this range will Inclusions present less difficulty
100% to locate or see under 10x.
3.5 K "face up" colorless when
53% to 57% mounted but larger ones will be magnification
6 VS2 4
34-1/2 o Variable*
4.0 L tinted.

4.5 M
** 7 S1 5 Inclusions are readily seen at 10x
o 5.0 N magnification, although they
40-3/4
remain invisible to the unaided
43% 5.5 O eye when the diamond is viewed
S2 6 face up.
6.0 P 8
6.5 Q One or more inclusions, or
7 their effect, can be seen by
THE AMERICAN CUT STANDARD 7.0 R Mounted stones in these I1 the unaided eye.
grades will display a yellowish
For Round Brilliant Cut Diamonds 7.5 S 9 tint even to the untrained eye. Inclusions are easily visible to
* Varies with table diameter to result in a 8
8.0 T the unaided eye.
34-1/2 degree crown angle I2
8.5 U Inclusions are so obvious and large
** 1% minimum thickness at the thinnest part to 9 that they affect both brilliancy and
9.0 V beauty of the diamond.
3% maximum thickness at the thickest part. 10
9.5 W I3 Shattered appearance or vivid
10 disfiguring and dangerous
10.0 XYZ inclusions and surface marks.
JISO 78 v.1/2013 (formerly ACORD 78) (Incl material copyrighted by JCRS, Jewelry Underwriting & Claim Mitigation) © JISO 2005-2013