Insurance Flood PFA

INSURANCE FLOOD PFA

Applicant / Insured Information

Applicant Name:

Entity Type: Individual Corporation Trust LLC Other

Property to Be Insured

Year Built:   Building Type:

Occupancy:   Stories:   Square Footage:

Foundation Type:   Basement Present: Yes

Flood Zone Designation:   FEMA Map Panel No.:   Elevation Certificate Available: Yes

Policy Details

Policy Type: Preferred Risk Policy Regular NFIP/Private Flood Policy High-Risk / Coastal Policy Other

Deductible Amount:   Annual Premium:

Policy Period From:   To:

Coverages Requested

Building Coverage Personal Property / Contents Additional Living Expense (ALE) Replacement Cost

Increased Cost of Compliance (ICC) Debris Removal Ordinance or Law Coverage Contents Off-Premises

Beneficiary / Loss Payee

Beneficiary Name:

Relationship to Insured:   Percentage of Proceeds:

Exclusions and Limitations

This application is subject to the insurer's underwriting guidelines and the terms, conditions, limits and exclusions of the issued policy. Coverage will not apply for loss or expense caused directly or indirectly by:

1. War, civil war, insurrection, nuclear hazard or governmental seizure; or damage caused by intentional acts of the insured; or by gradual deterioration, wear and tear, mold or vermin;

2. Loss resulting from earth movement including landslide or sinkhole, unless directly caused by flood as specifically covered by the policy;

3. Pollution, contamination or discharge of contaminants unless such discharge is directly caused by a flood event covered by the policy;

4. Any loss arising from fraud, misrepresentation, or material misstatement in this application or in any prior application for insurance; and other limitations set forth in the policy declarations and conditions.

By applying for coverage, the applicant acknowledges that coverage binding is conditional upon underwriting acceptance and receipt of required premium, and that any statements made in this application may be relied upon when issuing the policy. Applicant must disclose all material facts known at the time of application.

Please mark acknowledgment: I have read and understand the exclusions and limitations above.

Prior Flood Loss / Claim History

Have you sustained any flood loss or made a flood insurance claim for the property in the last 5 years?   Yes No

Documentation Checklist

Please attach available documents to support underwriting:

Declarations and Authorizations

The applicant certifies that all statements and answers contained in this application are true and complete to the best of the applicant's knowledge and that no material fact has been omitted. Misrepresentation or omission of material facts may give the insurer grounds for rescission or denial of coverage and may subject the applicant to penalties for insurance fraud.

The applicant authorizes the insurer, its agents, representatives and reinsurers to obtain information necessary to evaluate the application, including loss history, property inspections, and consumer reports as allowed by law. The applicant also authorizes release of claims payments to mortgagees or other loss payees identified on this application in accordance with the policy terms.

The applicant acknowledges that coverage will be provided only by issuance of a policy document specifying the coverage terms, limits, deductibles and exclusions. No binder or temporary insurance is effective unless and until the insurer expressly confirms coverage in writing and premium payment arrangements are satisfied.

Fraud Warning: Any person who knowingly and with intent to defraud an insurer files an application containing materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act and may be subject to civil and criminal penalties under applicable law.

Consent: I authorize inspection of the property for underwriting and claims purposes. I authorize the insurer to obtain reports necessary for underwriting. I authorize release of information to mortgagees or loss payees named above.

Sign Now