FEMA Flood Insurance Form

FEMA FLOOD INSURANCE APPLICATION AND DECLARATION

This Flood Insurance Application and Declaration (the "Application") is submitted by the Applicant for consideration of flood insurance coverage under the National Flood Insurance Program. The Applicant certifies that the information provided herein is true and complete to the best of the Applicant's knowledge and that submission of this Application creates no obligation on the part of the insurer until a policy is issued, accepted, and premium is paid in accordance with policy terms.

Applicant / Insured Information

Date of Birth:    Social Security / Tax ID (last 4):

Property to be Insured

Flood Zone:    Community Name / Number:

Lowest Floor Elevation (NAVD88):    Elevation Certificate Provided:

Coverage & Policy Details

Policy Type (select all that apply):
Building Coverage    Contents Coverage    Building & Contents

Policy Period: From To

Mortgagee / Loss Payee / Beneficiary

Coverage Options and Endorsements

Select optional coverages and endorsements to be included in policy issuance. Not all endorsements are available in every community; issuance is subject to underwriting review.

Replacement Cost Coverage for Building
Actual Cash Value (if applicable)
Increased Cost of Compliance (ICC)
Other Endorsement(s):

Exclusions, Limitations and Important Notices

The policy available through this Application provides coverage only for direct physical loss by flood as defined in the policy. The policy does not cover loss caused by:

• Earthquake, landslide, sinkhole, or other earth movement except as covered by an explicit endorsement;
• Wear and tear, deterioration, rust, corrosion, mechanical breakdown, inherent vice, latent defect;
• Ordinance or law requiring demolition, reconstruction, or modification except as provided by ICC;
• War, nuclear hazard, or intentional acts of the insured;
• Consequential loss, business interruption, or loss to property outside the stated insured premises unless specifically endorsed.

By signing this Application, the Applicant acknowledges receipt of and agreement to the foregoing exclusions and limitations and understands that the precise terms, conditions, limitations, and exclusions are contained in the policy form issued by the insurer.

Prior Flood Losses & Claims History

Applicant has prior flood loss(es)    Applicant has no prior flood loss(es)

Documentation Checklist

The following documentation is required for underwriting and must accompany this Application when submitted. Indicate documents included:

Elevation Certificate (if required)
Photographs of Property (interior and exterior)
Proof of Ownership or Interest
Prior Flood Insurance Policy or Claims Documents
Other Documents:

Agent / Broker

Declaration and Certification

I certify under penalty of law that the statements made in this Application are true and complete. I understand that any false or fraudulent statement made in connection with this Application may result in denial of coverage, rescission of any policy issued, and civil or criminal penalties. I authorize the insurer and its agents to obtain and verify information necessary to underwrite, issue, and service the policy, including but not limited to property inspection, claims history, and flood zone verification.

I acknowledge that issuance of coverage is subject to underwriting review and acceptance of premium. I understand that premium is earned pro rata from the effective date of the policy and that cancellation or nonrenewal provisions will be governed by the policy terms and applicable law.

I further certify that I have read, understand, and accept the terms, conditions, exclusions, and limitations contained in this Application and in any policy issued as a result of this Application.

Fraud Warning

Any person who knowingly and with intent to defraud submits an application containing false information or conceals information for the purpose of misleading may be subject to criminal prosecution and civil penalties. Additionally, false statements may void coverage and prohibit payment of claims.

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