Insurance Flood Check Form

INSURANCE FLOOD CHECK FORM

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Property Location & Description

Ownership Status: Owner-occupied Rental Vacant

Building Type: Residential Single-family Multi-family Commercial

Foundation Type: Slab Pier/Beam Raised Masonry Other

Flood Zone Designation (if known): Zone A Zone AE Zone V Zone X Unknown

Policy Details

Insurer:    Policy Number:

Policy Type: Standard Flood Increased Cost of Compliance Commercial

Coverage Limit: $    Deductible: $    Annual Premium: $

Policy Period: From to

Flood Assessment Checklist

Is an Elevation Certificate available? Yes No

Photographs of property exterior and interior
Prior flood claim reports
Repair invoices/receipts
Engineering or mitigation reports

Elevated structure
Flood walls/levees
Sealed foundation/openings
Sump pump with backup power

Prior Losses / Claims

Any prior flood claims for this property? Yes No

Estimated Exposure / Damage Potential

Coverage Selections / Limits

Desired Additional Coverages: Equipment/Business Personal Property Coverage
Contingent Business Interruption Coverage
Increased Cost of Compliance/Elevation Coverage

Exclusions and Limitations

The insurer does not provide coverage for loss or damage caused directly or indirectly by:

• Flooding that results from a deliberate act by the insured to cause a loss;
• Losses arising from landslide or earth movement unless directly caused by floodwaters;
• Wear, gradual deterioration, corrosion, or lack of maintenance;
• Loss to property located below the lowest floor unless specifically endorsed;
• Consequential losses including loss of business income except where an endorsement applies.

Beneficiary / Loss Payee (if applicable)

Inspection / Additional Notes

Declaration and Certification

I certify that the information provided in this Insurance Flood Check Form is true, complete and accurate to the best of my knowledge. I understand that this information will be used by the insurer for underwriting, rating and claims handling. I authorize the insurer and its representatives to inspect the property, obtain and verify records, and share this information with reinsurers, adjusters and parties with a lawful interest. I acknowledge that knowingly providing false or misleading information may result in denial of coverage, cancellation of the policy or other penalties under applicable law.

By signing below, I attest that I have disclosed all material facts known to me about the property's flood exposure and prior damage. I agree to notify the insurer promptly of any changes to the information provided herein.

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