Insurance Flood Signature Pack

INSURANCE FLOOD SIGNATURE PACK

Applicant / Insured Information

Policy Details

Policy Type: NFIP (Federal) Private Flood Policy Excess / Umbrella Flood

Coverage Options

Select coverages included in this policy:

Building (structure) coverage
Personal property (contents) coverage
Increased Cost of Compliance (ICC)
Loss of Use (additional living expenses)
Other coverages

Exclusions and Limits

The following are typical exclusions and limitations under flood insurance policies and may be applicable to this policy: wear and tear, groundwater seepage not caused by an identified flood event, pollutants, acts of war, and damage from movement of earth unrelated to flood. This list is illustrative and not exhaustive. The insured acknowledges that specific exclusions and limits are contained in the policy language and declarations.

By checking this box I acknowledge that I have received, read, and understand the exclusions and limitations described above and in my policy documents.

Mortgagee / Loss Payee / Beneficiary

If a mortgagee, lender, or other loss payee is to be named on the policy, provide details below. The insurer's obligation to the mortgagee is subject to the terms of the policy and any endorsements.

Claims Documentation & Attachments

Please indicate which documents are attached to support any pending or future claim for flood damages:

Elevation Certificate
Photographs of Damage
Proof of Ownership
Repair Estimates / Invoices
Other Documents

Authorizations, Assignment, and Certifications

By signing below the insured certifies the following under penalty of perjury and agrees to the authorizations and assignments set forth:

1. Authorization: I authorize the insurer, its representatives and contractors to inspect the insured premises, take photographs, and obtain relevant records from other insurers, mortgagees, and governmental agencies as necessary to evaluate coverage and adjust claims. I authorize the release of my flood loss history, prior claims information, and mitigation records to the insurer.

2. Assignment of Benefits: I elect to assign benefits under this policy to an assignee for purposes of claims payment. If assigning, provide assignee information below. Assignment is subject to policy terms, and the insurer may require separate assignment documentation.

3. Fraud Warning and Accuracy: I understand that knowingly providing false, incomplete, or misleading information to obtain insurance benefits is a criminal offense and may result in denial of claims, cancellation of coverage, and civil or criminal penalties to the extent permitted by law.

4. Cooperation and Subrogation: I agree to cooperate with the insurer in claims investigation and to execute documents necessary to allow the insurer to pursue subrogation rights against third parties responsible for loss.

5. Electronic Signature Consent: I consent to the use of electronic signatures, acknowledgements, and records for this insurance transaction and related communications. My electronic signature has the same force and legal effect as my handwritten signature.

Previous Flood Loss History

Yes No

Certification

I certify that the information provided in this Insurance Flood Signature Pack is true, complete, and accurate to the best of my knowledge. I understand that the insurer will rely upon these representations in issuing or renewing coverage and in handling claims. I agree to notify the insurer promptly of any material change in the information provided herein.

I further certify that I have authority to execute this document on behalf of all insured persons and entities named in this application, and that any misrepresentation may result in rescission of coverage or denial of claims as permitted by law.

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