Insurance Flood Home Application

INSURANCE FLOOD HOME APPLICATION

Application Date:   Agent/Broker:

Applicant / Insured Information

Property Information

Basement present: Yes    No

Policy Details

Policy Type:   Requested Effective Date:

Coverage Options (select applicable)

Building/Residential Structure
Personal Property / Contents
Additional Living Expenses (ALE)
Debris Removal
Ordinance or Law / Increased Cost of Compliance
Replacement Cost for Contents (if available)

Exclusions and Limitations

The policy for which this application is made contains exclusions and limitations that are hereby acknowledged by the applicant. Typical exclusions include but are not limited to:

1. Loss caused by earth movement, landslide, sinkhole, or similar geological activity unless specifically endorsed.
2. Loss arising from war, nuclear hazard, intentional acts by the insured, or criminal acts.
3. Loss due to wear and tear, deterioration, or faulty design, workmanship or construction.
4. Contamination, pollutants, fungi, or mold unless directly resulting from a covered flood loss and subject to policy limits.
5. Losses to motor vehicles and mechanical equipment not intended to be covered under building or contents provisions.

Past Losses & Claims History

Has the property sustained a flood loss or claim in the past 10 years?    Yes    No

Supporting Documentation Checklist

Please indicate which documents are attached or will be provided:
Elevation certificate (if available)
Prior flood insurance policy or declarations
Proof of ownership or mortgage statement
Photographs of the property and vulnerable areas
Other supporting documents (describe below)

Beneficiary / Loss Payee

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 any material misrepresentation, omission, or concealment of a fact may give the insurer the right to void coverage from its inception or deny a claim and may be punishable by law.

I authorize the insurer and its representatives to obtain and verify information that is relevant to underwriting and claims, including inspection of the property, verification of past loss history, and review of supporting documentation. I understand that acceptance of this application and the binding of coverage is subject to review by the insurer, payment of the required premium, and issuance of a policy document; coverage will not be effective until the insurer accepts the application and a policy is issued.

I agree to notify the insurer promptly of any change in occupancy, property condition, or other material facts occurring prior to the effective date of any policy issued in reliance upon this application.

By signing below, I acknowledge receipt of a copy of this application and consent to electronic or paper communications related to this application and any resulting policy.

Applicant acknowledges the insurer's right to inspect the insured property at reasonable times and to require corrective actions or mitigation measures as a condition of continuing coverage.

Acknowledgements (check all that apply)

I acknowledge the insurer's right to inspect the property.
I understand a failure to disclose material facts may void coverage.
I understand coverage is conditioned on payment of premium and issuance of a policy form.

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