Insurance Flood Policy Form

INSURANCE FLOOD POLICY FORM

Policy Identification

Insured / Applicant Information

Date of Birth:

Policy Coverage Summary

Coverage Limit (Building): $    Deductible: $

Coverage Limit (Contents): $    Deductible (Contents): $

Annual Premium: $

Policy Period: From    To

Coverage Options (select applicable)

Building Coverage    Limit: $

Contents Coverage    Limit: $

Increased Cost of Compliance (ICC)    Limit: $

Loss of Use / Additional Living Expense    Limit: $

Exclusions (standard)

The following are typical exclusions under this Flood Policy. The Insured acknowledges that cover under this policy does not apply to:

• Loss due to earth movement, subsidence, landslide, or other earth-related causes not directly resulting from flood;
• Loss or damage caused intentionally by or at the direction of the Insured;
• Loss due to acts of war, insurrection, or nuclear hazard;
• Losses covered by other insurance, unless specifically noted as excess;
• Damage to landscaping, trees, shrubs, and other unpaid attachments unless specifically endorsed.

I acknowledge and accept the standard exclusions listed above.

Mortgagee / Loss Payee

Beneficiary Designation

Claims Notification & Loss Details (to be completed at time of loss)

Date of Loss:

Photographs of damage    Receipts / invoices    Police / incident report

Declarations, Conditions, and Certification

The Insured declares that the statements and answers contained in this form are true and complete to the best of their knowledge and are material to the issuance of the policy. The Insured understands that a material misrepresentation, omission or concealment of fact may void coverage from inception and permit the Insurer to deny claims.

This policy is subject to the terms, conditions, limitations and exclusions contained herein and in any endorsements. The Insured agrees to permit inspection of the insured property by representatives of the Insurer, to cooperate in the investigation and adjustment of claims, and to take reasonable measures to protect the property from further damage after a loss.

Subrogation: To the extent of any payment under this policy, the Insurer shall be subrogated to the Insured's rights of recovery against any third party. The Insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights, and shall do nothing to prejudice them.

Fraud Warning: It is a crime to knowingly present false or fraudulent information in support of a claim for payment under an insurance policy. Intentional misstatements or concealment of material information in an application or claim may subject the Insured to criminal and civil penalties and denial of coverage.

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