Insurance Home Flood Application

INSURANCE HOME FLOOD APPLICATION

Applicant Name:   Applicant Type: Individual Entity/Business

APPLICANT / INSURED INFORMATION

PROPERTY TO BE INSURED

Year Built:   Occupancy Status: Primary Residence Secondary Residence Rental

Basement Present: Yes No   Foundation Type:

Flood Zone Designation (if known):   Elevation Certificate Available: Yes No

POLICY DETAILS

Policy Type: Building Contents Building & Contents

Premium Amount:   Policy Period From:  To:

Payment Plan: Annual Monthly Quarterly

COVERAGES SELECTED

Building Structure Coverage
Personal Property / Contents Coverage
Additional Living Expenses (ALE)
Debris Removal
Emergency Repairs / Services
Ordinance or Law (increased cost of compliance)

EXCLUSIONS AND LIMITATIONS

The applicant acknowledges that the flood policy contains detailed exclusions and limitations. Typical exclusions include, but are not limited to, loss or damage caused directly or indirectly by:

• Earth movement, landslide, or sinkhole not caused by flood
• Mold, fungus or bacterial contamination except as specifically provided by endorsement
• Intentional acts, war, nuclear hazard or government seizure
• Sewer backup or sump pump failure unless specific coverage is purchased

By checking the box below, the applicant certifies that they have read and understand the foregoing exclusions and limitations and that coverage is subject to the policy language. Applicant acknowledges exclusions

PRIOR LOSS HISTORY

Has the property sustained any flood loss in the past 5 years? Yes No

MORTGAGEE / BENEFICIARY INFORMATION

DOCUMENTATION CHECKLIST

Please indicate which documents are attached with this application:

Elevation Certificate
Photographs of Property
Prior Policy Declarations
Repair / Damage Estimates

DECLARATION AND CERTIFICATION

I hereby apply for flood insurance on the property described in this application. I declare that the information contained herein, including all attachments and supplemental statements, is true, complete and accurate to the best of my knowledge. I understand that any misrepresentation, omission, or concealment of material facts may result in denial of coverage, policy cancellation or rescission, or denial of claims, and may subject me to civil or criminal penalties under applicable law.

I authorize the insurer and its representatives to inspect the property and to obtain records necessary for underwriting, rating, issuance and claims handling. I understand that coverage will be subject to the terms, conditions, limits and exclusions of the policy issued. The effective date of coverage, if issued, is subject to underwriting approval and receipt of premium as required by the insurer.

I agree to notify the insurer promptly of any material change in occupancy, use, or condition of the property that would affect the risk. I certify that I am authorized to provide the information in this application and to enter into this agreement on behalf of any named insured or entity.

Applicant Signature below constitutes acceptance of the statements and authorizations contained in this application and certifies that the applicant has read and understands the exclusions, limitations and duties contained in this application and the policy.

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