Insurance Flood Policy Request

INSURANCE FLOOD POLICY REQUEST

Use this form to request consideration for a flood insurance policy. Completion of this request is an application for underwriting review only and does not bind coverage. The applicant certifies the accuracy of all statements and authorizes inspections and the release of loss history as necessary for underwriting and placement.

Applicant / Insured Information

Policy Details Requested

Desired Policy Type: Building Coverage Contents / Personal Property Building & Contents

Payment Plan: Annual Monthly Installment

Coverage Options

Select additional coverages requested: Additional Living Expense / Loss of Use Debris Removal Ordinance or Law / Increased Cost of Compliance Basement Contents Coverage (if available)

Prior Losses and Claims

Have you had prior flood-related claims on this property? Yes No

Mortgagee / Loss Payee

Beneficiary Information

Property Mitigation / Elevation

Flood mitigation measures in place: Flood vents Sump pump with discharge Building elevated on piers/columns

Elevation Certificate Available: Yes

If provided, date of elevation certificate:

Exclusions and Important Notices

Important: This request form is an application for underwriting review only. Coverage, limits and premium are subject to underwriting guidelines, property inspection, and receipt of any required premium or deposit. The insurer may refuse or limit coverage for loss resulting from excluded perils, including but not limited to: earth movement, surface water not defined as flood under the policy, gradual deterioration, infestation, wear and tear, ordinance or law unless specifically endorsed, and losses caused by intentional acts or fraudulent misrepresentation.

The applicant acknowledges that failure to disclose material facts or submitting false statements in connection with this request may result in denial of coverage, rescission of a policy, or denial of claims. The applicant authorizes the insurer and its representatives to obtain claim history, property loss history, and perform an inspection of the property for underwriting purposes.

Declaration and Authorization

I certify that the information provided in this Insurance Flood Policy Request is true, correct and complete to the best of my knowledge. I understand that this form is not an insurance policy and does not bind coverage. I authorize the insurer and its representatives to obtain relevant records for underwriting and claims handling, including prior loss information and mortgagee/lender information. I agree that any material misrepresentation or omission may be grounds for denial of coverage or rescission of any policy issued as a result of this request.

I further acknowledge that acceptance of this request by the insurer is conditioned upon satisfactory underwriting review, acceptance of premium, and completion of any required inspections or documentation. I understand that premium payment and policy issuance procedures, including any refund or cancellation provisions, will be governed by the policy contract if issued.

Agent / Broker (if applicable)

Sign Now