Insurance Homeowners and Flood Application Form

Insurance Homeowners and Flood Application Form

Applicant / Insured Information

Applicant Name:

Date of Birth:

Phone:    Email:

Property Information

Year Built:    Square Footage:

Construction Type:    Roof Type:

Occupancy (primary, seasonal, rental):    Distance to water body/floodplain:

Policy Details

Requested Policy Type: HO-3 (Special Form) HO-5 (Comprehensive) HO-4 (Renters) HO-6 (Condo)

Deductible:    Annual Premium (estimate):

Requested Policy Period Start:    End:

Flood Coverage Options

Provide flood insurance: Yes No

Flood Coverage Limit:    Flood Deductible:

Elevation certificate available: Yes No

Coverage Selection and Endorsements

Select optional endorsements (check all that apply): Ordinance or Law (increased costs) Earthquake Sinkhole Sewer Backup

Exclusions and Conditions

The insurer will not be bound to provide coverage until a policy is issued and the premium is paid. Coverage is subject to the terms, conditions, limitations and exclusions contained in the policy form. Typical exclusions include but are not limited to:

• Loss due to wear and tear, gradual deterioration, insects or vermin;
• Loss from intentional acts or fraudulent misrepresentation by the insured;
• Flood-related losses subject to separate flood policy terms and any mandatory waiting periods;
• Damage from war, nuclear hazard, or acts of government unless specifically endorsed;
• Losses arising from failure to maintain property in a reasonably safe condition.

Prior Insurance and Loss History

Number of claims in past 5 years:

Beneficiary / Mortgagee Information

Primary Mortgagee / Loss Payee Name:

Beneficiary Name:    Relationship:

Beneficiary Percentage of Proceeds: (Percentages must total 100% for multiple beneficiaries)

Documentation Checklist

Please attach the following documents where applicable:

Proof of ownership (deed or title)
Recent photographs of property
Elevation certificate
Prior policy declarations
Claims history / loss runs

Declarations and Certification

By signing below, the applicant certifies that all information provided in this application is true, complete and accurate to the best of the applicant's knowledge. The applicant understands that any material misrepresentation, omission or concealment of fact in this application or in the presentation of any claim may result in denial of coverage or rescission of the policy, and may subject the applicant to civil or criminal penalties under applicable law.

The applicant authorizes the insurer or its authorized representative to inspect the insured property, obtain relevant records, and to request prior loss history from other insurers. The applicant agrees to notify the insurer of any material changes in occupancy, property condition, or risk characteristics prior to policy inception or renewal.

Binding of coverage is subject to underwriting approval, issuance of a policy form with terms and endorsements, and receipt of premium in accordance with the insurer's procedures. Quotations provided prior to policy issuance are estimates and do not bind coverage.

Authorization to Release Information

The undersigned authorizes any person or organization to release to the insurer or its representatives any information concerning property condition, prior insurance coverage, claim history, or other information necessary to underwrite and service the policy. A copy of this authorization shall be as valid as the original.

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