Insurance Flood Transfer Application

INSURANCE FLOOD TRANSFER APPLICATION

Use this application to request transfer, assignment, or change of record for a flood insurance policy affecting the described property and insured. Completion of this form constitutes a written request and authorizes the insurer and its agents to review policy records and effect the requested transfer subject to underwriting and policy terms.

Applicant / Insured Information

Date of Birth:    Identification (last 4 digits SSN or tax id):

Current Policy Information

Policy Period Start:    Policy Period End:

Property (Risk) Location

Transfer Details

Transfer Requested: Transfer of ownership due to sale or conveyance
Assignment of policy to new insured
Change of record / change of insured name
Other (specify in reason)

New Insured Date of Birth (if individual):

Coverage Selection & Options

Indicate coverages currently in force and those to be continued after transfer.

Exclusions & Acknowledgements

The undersigned acknowledges that standard flood insurance exclusions apply unless expressly endorsed. Exclusions commonly include but are not limited to: loss due to earth movement except as specifically endorsed; losses arising out of war or nuclear hazard; wear and tear, deterioration or latent defects; losses covered by ordinance or law only as endorsed; pollution and contamination; damage existing prior to policy effective date; and losses caused by intentional acts of the insured.

Beneficiary for Policy Proceeds (if applicable)

Documentation Checklist

Attach or indicate documents submitted in support of the transfer request:

Declarations, Authorizations and Certifications

By submitting this application the undersigned certifies under penalty of law that the information provided in this application and any attached documentation is true, correct and complete to the best of the applicant's knowledge. The applicant authorizes the insurer and its authorized representatives to obtain, verify and use any information necessary to process this transfer request, including but not limited to policy records, property records and loss history.

Applicant understands that any transfer or assignment is subject to the insurer's underwriting review and approval and may result in adjustment of premium, change in coverage, imposition of endorsements, or denial. Applicant agrees to pay any transfer fees, prorated premiums, or premium adjustments that may become due as a condition of effecting the transfer. The insurer's acceptance of a transfer request does not waive any rights to apply policy terms, conditions, limitations and exclusions.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company submits an application containing false information or conceals for the purpose of misleading information concerning any fact material thereto may be guilty of insurance fraud and subject to civil and criminal penalties under applicable law.

Applicant further agrees to indemnify and hold harmless the insurer and its agents for any liability arising from inaccuracies in the information supplied for purposes of this transfer, except to the extent such liability arises from the insurer's own wrongful act or omission.

Sign Now