Excess Flood Insurance Application

Date:

Insured:

Mailing Address:

City: State: Zip:

County:

Property Address (if different):

City: State: Zip:

County:

Primary Flood Ins. Carrier:

Policy Number:

If XS of XS:

Excess Flood Ins. Carrier:

Excess Flood Ins. Policy No.:

PLEASE CHECK ALL THAT APPLY:

Residential:

Single Family

2-4 Family

Single Condo unit

Primary Residence

Secondary Residence

Tenant Occupied

First Mortgagee:

Loan#:

Address:

City: State: Zip:

Agency Name:

Contact:

Address:

City: State: Zip:

Phone:( ) Fax:( )

E-mail:

Surplus Lines Broker:

SWBC Other:

Company Name

Address:

City: State: Zip:

Phone:( ) Fax:( )

Tax ID#:

Commercial:

Condo.Bldg. Apt.Bldg. # of Units:

Hotel / Motel # of Units:

Other:

How long has the insured owned or occupied the building? Years Months New Purchase/New Occupancy

Flood Zone: Yr. Built: No. of Floors (incl. Basemnt): Pre- OR Pre-OR Post-FIRM: Elev. Difference:

A zone risks w/neg. Elev. Diff. and w/in 1000’ of water are ineligible. V zone risks must be on pilings. V zones w/neg. Elev. Diff. are ineligible.

Basement? Y N Elevated Bldg? Y N On pilings? Y N Enclosure Y N Size: sf

Construction: Frame Fire-resistiv Masonry Other Use: Garage Access Storage Other

Distance from source of flooding: Describe source of flooding:

Have there been any flood losses? Yes No If Yes: Loss Date: Amount of loss:$

Please describe. Include bldg/conts loss amounts:

Commercial Contents: Describe: Skidded or shelved? Height Above Floor:

For V Zone Inspection: Contact Name: Telephone:( )

Residential risks must be insured to a total of 80% of the building RCV or the maximum limit available, whichever is less.

Primary SF residences: Add $5,000 Additional Living Expense Coverage? Y N

DESIRED EFFECTIVE DATE:

Coverage will be effective on the proposed effective date shown above or five (5) days after this application (with premium payment) has been date-stamped by the appointed broker and accepted by the Underwriter, WHICHEVER IS LATER.

ACCEPTANCE OF THIS APPLICATION DOES NOT BIND THE UNDERWRITERS TO COMPLETE THIS INSURANCE.

This application will be made part of the Insurance Policy. The undersigned warrant the truthfulness of this information, which will be material in the event of a claim under the policy. Any misrepresentation or concealment herein could void the coverage.

SWBC reserves the right to cancel coverage upon receipt of an unsatisfactory inspection report or any other information relating to the property which does not meet our underwriting requirements. The underlying coverage must be written at maximum limits.

COVERAGE HEREUNDER WILL CEASE IF THE UNDERLYING COVERAGE LAPSES OR IS CANCELLED OR NON-RENEWED.