Insurance Flood Coverage Form

INSURANCE FLOOD COVERAGE FORM

Applicant / Insured Information

Applicant Name:    Policy Number:

Date of Birth:    Phone:    Email:

Policy Details

Coverage Limit (Building):    Contents Limit:

Deductible:    Annual Premium:

Policy Period: From to

Coverage Selections

Building (Physical loss to the insured structure) — Limit:

Contents / Personal Property — Limit:

Increased Cost of Compliance (ICC) — Limit:

Additional Living Expense / Loss of Use — Sub-limit:

Sewer / Drain Backup Endorsement (if applicable)

Exclusions and Limitations

The following represent standard exclusions and limitations under the flood coverages selected. Losses caused directly or indirectly by earth movement, landslide, subsidence, volcanic eruption, war, nuclear hazard, intentional acts by the insured, wear and tear, gradual deterioration, or mechanical breakdown are not covered. Additional exclusions include but are not limited to sewer and drain backup unless the Sewer / Drain Backup Endorsement is selected and any pollution or contamination not caused by a covered flood event.

Coverage for newly acquired structures, elevated foundations, and detached structures is subject to policy conditions and may require endorsement or additional premium. Limits of liability, waiting periods, and sublimits apply as stated in the policy declarations.

I acknowledge that I have read and understand the exclusions, conditions, and limitations set forth above and in the policy contract.

Beneficiary / Mortgagee Information

Mortgagee Name:

Relationship to Insured:    Beneficiary Percentage:

Claim Information (To be completed when reporting a loss)

Date of Loss:    Time of Loss:

Estimated Damage Amount:

Photographs of damage

Repair estimates or contractor bids

Proof of ownership / receipts for items claimed

Flood incident report or local authority documentation (if available)

Declarations, Certifications and Consent

I declare that the statements and answers in this form are true, complete, and correctly recorded to the best of my knowledge and belief. I understand that any material misrepresentation, concealment, or omission of fact may be grounds for denial of coverage, adjustment of claim payment, or rescission of the policy pursuant to the terms of the policy contract and applicable law.

I authorize the insurer or its authorized representative to inspect the insured property, request and obtain records necessary to evaluate coverage and loss, and to provide or obtain information to coordinate recovery and claims handling. I understand that coverage is subject to policy terms, conditions, limitations, and applicable endorsements.

I agree that any payments due for covered loss will be made according to the policy provisions and, where a mortgagee or loss payee is named, in accordance with the interests described. I further certify that I will mitigate further damage and preserve property for inspection as required by the policy.

I certify that the information provided on this form is true and complete and that I understand the duties and obligations set forth above.

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