Insurance Flood Application Document

INSURANCE FLOOD APPLICATION DOCUMENT

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Property to be Insured

Occupancy Type:    Year Built:

Construction Type:    Number of Stories:

Basement Present:    Basement Use (if any):

Flood Zone Designation (per local mapping):    Lowest Floor Elevation (NAVD88):

Policy Details Requested

Coverage - Building: $    Coverage - Contents: $

Deductible: $    Estimated Annual Premium: $

Requested Policy Period From: To:

Selected Coverages (check all that apply)

Building Structure Coverage

Personal/Business Contents Coverage

Additional Living Expenses / Loss of Use

Basement Coverage (limited) — subject to underwriting

Increased Cost of Compliance (ICC)

Exclusions and Important Notices

The undersigned acknowledges that flood insurance policies exclude certain losses, including but not limited to loss caused by earth movement not caused by flood, acts of war, intentional loss, routine sewer backup absent a flood, or losses excluded by the policy's terms. Coverage is subject to limits, deductibles, and specific policy definitions of "flood" and covered property. Acceptance of coverage is subject to underwriting review and premium payment.

Applicant acknowledges receipt of and responsibility for reviewing the policy contract when issued. Applicant understands that misrepresentation of material facts or failure to disclose prior losses may result in denial of coverage or rescission of the policy.

I acknowledge that I have read and understand the exclusions and notices above.

Beneficiary / Mortgagee / Loss Payee Information

Relationship:    Percent Share:

Risk Mitigation and Property Protection

Flood vents / openings installed

Utilities/equipment elevated above base flood elevation

Sump pump with backup power installed

Prior Flood Loss History

Prior flood claims in the last five (5) years: Yes    No

Documentation Checklist (attach to application)

Elevation Certificate (if available)

Photographs of property and areas of concern

Proof of Ownership / Mortgage Statement

Prior Policy Declarations (if applicable)

Declaration and Certification

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that material misrepresentation or omission of facts may result in cancellation of coverage or denial of claims. I authorize the insurer, its agents, and representatives to obtain and verify information necessary to underwrite and service this policy, including property inspections and claims history from prior insurers and reporting services as permitted by law.

I understand that issuance of a flood insurance policy is subject to underwriting approval and receipt of full premium. I also understand that payment of any premium does not create coverage until a policy is issued in writing and delivered. I acknowledge my duty to report any material changes to property condition or occupancy promptly.

Warning: Any person who knowingly and with intent to injure, defraud, or deceive any insurer submits an application or statement of claim containing false, incomplete or misleading information may be subject to civil and criminal penalties under applicable law.

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