Insurance Flood Policy Packet

INSURANCE FLOOD POLICY PACKET

Applicant / Insured Information

Policy Details and Declarations

Policy Number:    Agent/Broker:

Coverage Options Selected

Building structural coverage    Limit:

Personal property / contents coverage    Limit:

Additional living expense (ALE)    Limit:

Replacement cost endorsement (if available)

Policy Exclusions & Important Notices

The following are typical exclusions under this flood policy unless specifically endorsed: loss due to earth movement, war or military action, wear and tear, gradual deterioration, infestation, theft unrelated to flood, and damage arising from failure to maintain protective devices. This policy does not cover loss caused by sewer or drain backup except where a specific endorsement provides coverage.

By checking the box below the Applicant acknowledges receipt of and agreement to the stated exclusions and understands coverage is governed by the terms, conditions and endorsements contained in the issued policy.

I acknowledge that I have read and understand the policy exclusions described above.

Beneficiary / Loss Payee Designation

Designate one or more beneficiaries or loss payees for proceeds related to this policy.

Mortgagee / Loss Payee Information

Notice of Loss / Claim Information (For Immediate Use)

Date of loss:    Cause of loss:

Documentation submitted (check all that apply):

Photographs of damage
Repair estimates
Official report (if applicable)
Receipts / proof of ownership
Other supporting documentation

Declarations, Authorizations and Fraud Notice

I certify that the statements and answers in this packet are true and complete to the best of my knowledge. I understand that coverage under this policy is subject to the terms, conditions, limitations and exclusions contained in the issued policy contract and any endorsements. I authorize the insurer, its representatives and agents to obtain records and information necessary to underwrite and service this policy, including inspections of the insured property. I acknowledge that any material misrepresentation, omission, or fraud may result in denial of coverage and may subject me to civil or criminal penalties under applicable law.

Premium is due in accordance with the policy schedule. The company retains the right to cancel or nonrenew the policy as permitted by the policy terms and applicable law. Receipt of this packet does not constitute a binder of coverage unless a separate binder or declaration to that effect is issued in writing.

I certify that I have read and agree to the above declarations and authorizations.

Acknowledgment of Privacy and Inspections

I consent to the insurer's collection and use of personal information for underwriting, claims investigation, fraud prevention, and policy administration. I further consent to reasonable inspections of the insured property by the insurer or its representatives for underwriting or loss assessment purposes.

I consent to the uses and inspections described above.

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