Insurance Flood Surplus Line

INSURANCE FLOOD SURPLUS LINE

Applicant / Insured Information

Individual Corporation Trust LLC

Property to Be Insured

Policy Details

Policy Type:    Policy Number (if known):

Replacement Cost - Building Actual Cash Value Contents Coverage Additional Living Expenses Basement Coverage (limited) Ordinance or Law Coverage Debris Removal

Loss History & Prior Flood Losses

Prior Flood Losses in Past 5 Years: Yes No

Mortgagee / Loss Payee

Exclusions, Limitations and Conditions

This surplus lines flood policy is issued subject to the insurer's policy form, endorsements and the following general exclusions. Coverage does not apply to: earth movement or landslide except to the extent directly caused by flood; wear, deterioration, mechanical or electrical breakdown; war or nuclear hazard; intentional acts by the insured; pollution except where directly caused by flood; sewer or drain backup unless a specific endorsement is purchased. Coverage is further limited by specific sublimits, waiting periods and conditions set forth in the policy form.

The insured must maintain the property and remove or mitigate known hazards. Failure to comply with reasonable mitigation or maintenance requirements, or any material misrepresentation in this application, shall entitle the insurer to deny coverage or rescind the policy in accordance with the policy terms.

Surplus Lines Placement Notice & Important Statements

This insurance is placed as a surplus lines placement with an insurer not licensed in all jurisdictions. The policy is subject to surplus lines placement laws and may not afford the same regulatory protections as admitted market policies. Premiums, taxes and fees applicable to surplus lines transactions may be collected and remitted in accordance with applicable law.

Arbitration, dispute resolution, subrogation, assignment and cancellation provisions, including any short-rate or pro rata refund provisions, are governed by the terms of the issued policy and applicable surplus lines rules. The applicant acknowledges that coverage is subject to the insurer's underwriting review and may be modified, restricted or declined.

Declarations & Certifications

By signing below the applicant declares that the information provided in this application is true, complete and correct to the best of the applicant's knowledge. The applicant acknowledges that material misstatements or omissions may result in denial of coverage, rescission of the policy, or forfeiture of claims. The applicant authorizes the insurer, its representatives and its authorized agents to obtain and disclose any information reasonably related to underwriting, quoting, or claim settlement, including inspection reports, prior loss history, and property condition surveys.

Authorizations & Consent

The applicant consents to electronic delivery of policy documents and notices where permitted and to the release of information to mortgagees or loss payees named above for the purpose of protecting their interest. The applicant acknowledges responsibility for payment of premium and any applicable taxes, fees or surcharges required by law or by the surplus lines placement.

I authorize the insurer and its designees to access relevant records and to perform inspections necessary for underwriting and claim handling. I understand that coverage will not be effective until accepted by the insurer and any required premium is paid in accordance with the insurer's billing terms.

I acknowledge receipt of all policy terms and exclusions upon issuance and understand that endorsements and specific conditions will be attached to the policy as issued.

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