Insurance Flood Declaration Page

INSURANCE FLOOD DECLARATION PAGE

Insurer and Policy Information

Insurer Name:

Policy Number:    Policy Type:

Effective Date:    Expiration Date:

Issuing Agent/Broker:

Insured / Named Insured

Property Location (if different):

Date of Birth (if individual insured):    Contact Phone:

Property Description

Year Built:    Number of Floors:    Basement/Subgrade:

Flood Zone and Mapping

Flood Zone Classification:    Map Panel Number:

Community Name / Municipality:

Base Flood Elevation (if applicable):    Elevation Certificate Provided:

Coverage Summary

Building Coverage Limit: $    Personal Property Limit: $

Other Structures Limit: $    Loss of Use (Additional Living Expense) Limit: $

Deductible: $    Basis of Loss Payment:

Premium and Fees

Annual Premium: $    Policy Fee / Surcharges: $

Total Due at Inception: $

Optional Endorsements and Coverage Options

Replacement Cost on Building:    Increased Cost of Compliance:    Ordinance or Law Coverage:

Exclusions

The coverage provided by this Flood Declaration Page is subject to exclusions set forth in the Flood Insurance Policy terms and conditions. Notwithstanding any other provision, this policy does not cover loss caused directly or indirectly by:

• Acts of war, insurrection, nuclear hazard, or government seizure;
• Earth movement, landslide, sinkhole or gradual earth settling not caused by flood;
• Pollutants, contaminants, or discharge of hazardous materials;
• Intentional acts, criminal acts, fraud, or willful misconduct by the insured;
• Losses otherwise excluded by endorsements or by condition of the policy (e.g., sewer or drain backup where not specifically endorsed).

Conditions and Important Notices

Premium is due in accordance with the policy and is a condition precedent to coverage. Failure to pay premium when due may result in cancellation of coverage in accordance with the policy terms. Coverage applies only to loss that occurs during the policy period and within the limits and subject to the deductibles stated herein.

It is a material representation that the information contained in this Declaration Page is true and correct to the best of the insured's knowledge. Material misrepresentation, concealment of a material fact, or fraud may result in denial of coverage or rescission of the policy to the extent permitted by law.

The insured must provide prompt notice of loss, take reasonable steps to protect property from further damage, and cooperate with the insurer in the investigation and adjustment of any claim. Proof of loss requirements and time limits are governed by the policy.

Beneficiary Designation

If proceeds are payable to a designated beneficiary, the following designation applies for loss payments under the policy.

Relationship to Insured:    Percentage of Proceeds: %

Declaration and Certification

By signing below, the named insured certifies that the statements and representations contained in this Flood Declaration Page are true and complete. The insured acknowledges that this Declaration Page, together with the Flood Insurance Policy and any endorsements attached, constitute the entire agreement of insurance between the insured and the insurer with respect to the coverages listed.

The insured understands that coverage is subject to all terms, conditions, limitations and exclusions of the Flood Insurance Policy and that this Declaration Page does not alter such policy provisions except as expressly provided by endorsement.

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