Insurance Flood Change Form

INSURANCE FLOOD CHANGE FORM

Insured Name:   Policy Number:

Applicant / Insured Information

Date of Birth:   Phone:   Email:

Policy Details

Existing Policy Type: Standard Flood Policy Preferred Risk Policy Wind/Flood Combined

Current Deductible:   Current Annual Premium:

Policy Period Start:   Policy Period End:

Requested Change

Requested Effective Date:   Reason for Change:

Increase Building Limit Decrease Building Limit Add / Increase Contents Change Deductible

Coverage Options & Flood Risk Information

Coverage Requested: Building Coverage Contents Coverage Additional Living Expenses (ALE) Debris Removal

Flood Zone Classification:   Community Rating:

Elevation Certificate on File: Yes No, request elevation   Elevation Certificate Date:

Exclusions and Limitations

The undersigned acknowledges that flood insurance does not cover loss caused by any of the following unless specifically endorsed: earth movement, mold or mildew except as a direct result of flood, settling or structural defects, normal wear and tear, and damage to landscaping, wells, septic systems, vehicles, or property outside the insured building. Any increase in coverage is subject to underwriting review and acceptance by the insurer and may be subject to revised premium, waiting periods, or denial based on eligibility and map reclassification.

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

Documentation Checklist

Please indicate which documents are attached or will be provided for underwriting:

Elevation Certificate
Photographs of Property
Repair/Replacement Estimate
Proof of Ownership/Deed
Prior Flood Policy Declaration Page

Change in Response to Claim or Loss (if applicable)

Is this change related to a reported loss? Yes

Declaration and Applicant Certification

I certify that the information provided in this Insurance Flood Change Form is true and complete to the best of my knowledge. I understand that any misrepresentation or omission of material facts may result in denial of the requested change, cancellation of coverage, or rescission of the policy. I authorize the insurer and its representatives to obtain and verify information necessary to underwrite and effect this change, including inspection of the insured property and review of elevation certificates and flood map data. I understand that acceptance of this requested change is subject to underwriting review and payment of any additional premium and that an effective date will be assigned only after insurer approval and receipt of required documentation and premium adjustments.

By signing below, I acknowledge that I have read and understand the terms of this request and that I am authorized to request changes to the policy identified above.

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