Insurance Flood Affirmation Form

INSURANCE FLOOD AFFIRMATION FORM

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Property Location (Risk Address)

Year Built:    Number of Floors:    Primary Building Use:

Policy Details

Policy Number:    Policy Type:

Coverage Amount (Building): $    Contents Limit: $

Deductible: $    Annual Premium: $

Policy Period From: to

Flood Exposure Assessment

Does the insured property lie within a designated flood hazard area (as represented by local floodplain ordinances or flood insurance rate maps)? Yes No

Is the lowest adjacent grade or lowest floor below the Base Flood Elevation? Yes No

Elevated structure    Permanent barriers (levee, berm)    Improved site drainage    Other:

Coverage Selection

Select requested coverages (checking a box constitutes a request for that coverage subject to underwriting approval):

Building Property Coverage    Personal/Business Contents Coverage    Additional Living Expense Coverage    Separate Deductible Option

Exclusions, Limitations and Declarations

The insured affirms that the statements contained in this form are true and complete to the best of the insured's knowledge. Coverage pursuant to any flood insurance policy issued shall be subject to all terms, conditions, exclusions, definitions and limitations contained in the insurance contract. Flood insurance does not cover losses caused by earth movement, mold or gradual deterioration unless specifically endorsed.

The insured understands that material misrepresentation or omission of information in this affirmation or in the application for insurance may result in denial of coverage, rescission of the policy, reduction of benefits, or other remedies permitted by law. The insured authorizes the insurer and its representatives to inspect the property, obtain flood zone determinations and elevation information, and to share information with reinsurers and other insurers for underwriting and claim handling purposes.

This affirmation is submitted as part of the underwriting record and will form a basis for any policy issued. Coverage shall be effective only upon issuance of an insurance policy and receipt of any required premium, subject to the policy terms.

Prior Flood History

Have you had any flood insurance claims or flood-related losses for this property in the past ten (10) years? Yes No

Beneficiary / Payee Designation

Designate a payee for proceeds if policy requires a payee other than the named insured (use only where applicable).

Relationship:    Percentage of Proceeds:

Mortgagee / Lienholder Information

Documentation Checklist

Attach copies of the following documents as applicable (check each provided):

Elevation Certificate    Prior Flood Insurance Policy    Photographs of Property    Repair/Replacement Estimates

Declarations and Affirmation

By signing below, the applicant certifies under penalty of perjury that the information provided in this Flood Affirmation Form is true, accurate and complete. The applicant acknowledges that the insurer will rely upon these statements in issuing flood insurance, setting terms and determining premiums. The applicant further acknowledges that any intentional misrepresentation of material facts may render the policy void or result in denial of claims and may subject the applicant to civil or criminal penalties as provided by law.

The applicant authorizes the insurer or its agents to obtain, verify and exchange information including but not limited to property elevation data, flood zone determinations, prior loss history, and other underwriting information from public records, prior insurers, or other entities as necessary for underwriting and claim administration.

Sign Now