Insurance Flood Renewal Form

INSURANCE FLOOD RENEWAL FORM

1. Applicant / Insured Information

Date of Birth:    Contact Phone:    Email:

2. Policy Details — Renewal

Policy Number:    Policy Type:

Effective From:    To:

3. Coverage Options (select all that apply)

Building (Structure) Coverage
Personal Property (Contents) Coverage
Additional Living Expense (ALE)
Replacement Cost Settlement
Actual Cash Value (ACV) Settlement

4. Property Information

Occupancy:    Construction Type:

Foundation Type:    Lowest Floor Elevation (NAVD88 or local datum):

5. Flood Mitigation / Loss Prevention

Select applicable mitigation measures installed at the risk location:
Elevated foundation / structure
Dry floodproofing
Flood vents / openings
Sump pump with check valve
Permanent barriers / levees

6. Prior Loss/Claims History (previous 5 years)

No prior flood claims in the past five years:

7. Mortgagee / Loss Payee / Beneficiary

8. Exclusions, Conditions and Important Notices

By submitting this renewal form the insured certifies that all statements herein are true and complete to the best of their knowledge. The policy being renewed is subject to the terms, conditions, limitations and exclusions contained in the policy document. Typical exclusions include, but are not limited to, earthquake-induced flooding, landslide or mudflow, contamination, wear and tear, preexisting damage, war and intentional acts. This Renewal Form does not extend coverage beyond the limits, hazards, or perils specifically described in the policy contract except as expressly amended in writing by the insurer.

The insured must promptly report any material change in risk, occupancy, or property condition that occurs prior to or during the policy period. Failure to disclose material changes may result in denial of coverage, policy rescission, or adjustment of premium. The insurer reserves the right to inspect the risk location and obtain repair, elevation, and mitigation documentation.

Fraud Warning: Any person who knowingly presents false information or conceals material information in connection with an insurance transaction may be guilty of insurance fraud under applicable law and subject to criminal or civil penalties.

9. Authorization and Certification

I, the undersigned, declare that the information provided on this Insurance Flood Renewal Form is true, correct and complete. I understand that this form, together with the policy declarations and terms, constitutes the basis for renewal of coverage, and any material misrepresentation or omission may render the policy voidable or subject to adjustment. I authorize the insurer and its representatives to obtain and verify information necessary to underwrite and service this policy, including inspection reports, mitigation records, and claims history from prior insurers or other sources. I acknowledge that renewal is subject to underwriting approval and receipt of any required premium.

Payment Authorization: I authorize the insurer to charge premium and fees to the payment method on file or to invoice the named insured for premium due. Renewal is not effective until any required premium is received or as otherwise provided in the policy terms.

I consent to receive communications, notices and policy documents by electronic means to the email address provided above unless I notify the insurer otherwise:

10. Additional Remarks / Instructions

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