Insurance Non-Flood Coverage Application

INSURANCE NON-FLOOD COVERAGE APPLICATION

Applicant / Insured Information

Property / Risk to be Insured

Policy Details

Requested Policy Period: From to . Coverage applied for is non-flood perils only; flood coverage is excluded from this application and will not be bound under the resulting policy unless a separate flood endorsement or policy is procured.

Coverages Requested (check all that apply)

Dwelling / Building Coverage
Personal Property / Contents Coverage
Loss of Use / Additional Living Expenses
Personal Liability Coverage
Other Structures Coverage
Ordinance or Law Coverage (Limited)

Exclusions and Limitations (Acknowledgement)

Applicant acknowledges that the coverage applied for expressly excludes losses caused by flood, surface water, tidal wave, storm surge, or any rising of ground or surface waters. The insurer may also exclude losses resulting from wear and tear, gradual deterioration, ordinance requiring demolition or reconstruction beyond limited coverage, and intentional acts of the insured. Additional specific exclusions may be contained in the policy form and endorsements. Applicant must review the policy document for complete terms, conditions, and exclusions.

Beneficiary / Mortgagee Information

Prior Insurance and Loss History

No known claims or losses
Yes — provide details below

Documentation Checklist

Provide copies of the following as applicable. Check boxes to indicate attached documentation.

Deed / Proof of Ownership
Recent Photographs of Property
Prior Insurance Policy (Declarations Page)
Repair or Damage Estimates
Mortgagee or Lender Letter of Interest

Agent / Broker (if applicable)

Declarations, Authorizations and Certification

By signing below, Applicant certifies that the information contained in this application is true, complete and accurate to the best of Applicant's knowledge. Applicant understands that any material misrepresentation, omission or concealment of fact in this application may render any resulting policy voidable as to all coverage for the risk or risks affected and may constitute insurance fraud.

Applicant authorizes the insurer, its representatives and its designees to make inquiry and to obtain records relevant to this application including but not limited to prior insurance claims, loss history, credit and underwriting information, inspection reports, and property appraisal records. Applicant further authorizes third parties to release such information to the insurer for underwriting and claim handling purposes.

Applicant agrees that any coverage bound as a result of this application shall be subject to the policy terms, conditions, limitations and exclusions set forth in the insurer's standard policy form and any endorsements issued thereafter. Payment of premium does not create liability on the part of the insurer until coverage is specifically accepted and a policy or binder is issued by the insurer or its authorized representative.

Fraud Warning: Under applicable law, knowingly presenting false or fraudulent information for the purpose of obtaining insurance coverage or payment of a claim may constitute a crime and may subject Applicant to criminal and civil penalties.

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