Insurance Application Flood End

INSURANCE APPLICATION — FLOOD END

Applicant / Insured Information

Applicant Name:

Policy Details

Policy Type: Dwelling Residential Renter Commercial

Policy Period From: to

Coverage Options

Select coverage to apply on this policy. Selections modify terms, limits, and premium as set forth in the policy contract.

Building/Structure Coverage
Personal Property / Contents Coverage
Additional Living Expenses (ALE)
Basement and Below-Grade Coverage
Immediate Emergency Repair Coverage

Exclusions and Limitations

The flood insurance policy will be subject to exclusions including, but not limited to: ordinance or law, earth movement (including subsidence and landslide), war and hostile acts, nuclear hazard, intentional loss, wear and tear, and loss caused by lack of maintenance. The insurer's obligation to pay benefits is limited to the perils and amounts described in the policy.

Applicant acknowledges receipt and review of the policy exclusions and understands that coverage is not provided for excluded perils. Applicant must initial to acknowledge understanding:

Loss Payable / Mortgagee / Additional Interest

Claims History

Has any property to be covered sustained a flood loss in the last five (5) years? Yes No

If yes, Date of Loss:

Documentation Checklist

Provide copies of the following where applicable. Failure to provide requested documentation may delay underwriting or result in declination of coverage.

Recent exterior and interior property photographs
Floor plan or building blueprint
Copies of previous flood-loss claim forms and settlement records
Proof of ownership or lease agreement

Agent / Producer Information

Declarations, Representations, and Authorization

The undersigned hereby applies for flood insurance coverage and represents that all statements contained herein are true and complete to the best of the undersigned's knowledge and belief. The undersigned understands that this application, including any attachments and declarations, will form the basis of any policy issued and that any material misrepresentation or omission may result in denial of coverage or rescission of the policy.

By signing below, the applicant authorizes the insurer and its representatives to inspect the described property, to obtain such information as may be necessary for underwriting and claims investigation, and to provide or exchange information concerning the applicant's claims history with other insurers and reporting agencies. The applicant acknowledges that coverage is not effective until the insurer accepts the application and payment of premium is received, subject to the insurer's underwriting rules and the terms, conditions, endorsements, and exclusions of the policy.

I certify under penalty of law that the foregoing statements and any attachments are true and complete. I understand that any false statements, misrepresentations, or concealment of material facts may be subject to civil or criminal penalties under applicable law, and may void any coverage issued based on this application.

Applicant consents to receipt of policy documents and notices by electronic or physical delivery as permitted by the insurer's practices. Applicant acknowledges responsibility for payment of all premiums and fees applicable to the requested coverage.

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