Insurance PFA (Flood Policies)

Insurance PFA (Flood Policies)

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Property / Location of Risk

Property Type:    Year Built:    Elevation Certificate on File:

Policy Details

Building Coverage Amount: $    Contents Coverage Amount: $

Deductible: $    Annual Premium: $

Policy Period: From through

Coverage Selections

Select coverages to be bound under this Flood Policy. Checking a box indicates selection of that coverage subject to policy terms and limits.

Building Structural Coverage

Personal Property / Contents Coverage

Additional Living Expense (ALE) Coverage

Ordinance or Law Coverage (Code Upgrade)

Basement and Below-Grade Coverage (if available)

Optional Endorsements

Contents Replacement Cost Endorsement

Higher Limits Endorsement (where available)

Split Deductible Endorsement (building/contents separate)

Exclusions, Limitations and Acknowledgements

The policy issued in reliance on this application will contain exclusions, conditions, and limitations including, without limitation: losses resulting from earth movement not caused by flood; losses due to ordinances except as expressly endorsed; losses arising from intentional acts; losses resulting from war or nuclear hazard; and coverage subject to sublimits for jewelry, currency, and certain high-value items. The full terms and conditions in the policy govern coverage.

By initialing and signing below the applicant certifies that all occupancy, mitigation, and prior claims information provided is true and complete to the best of the applicant's knowledge. The applicant acknowledges that any material misrepresentation may result in denial of coverage or rescission of the policy.

I acknowledge I have read and understand the exclusions and limitations described above:

Beneficiary Designation (for Claims Proceeds)

Designate one or more beneficiaries to receive claim proceeds in the event of total loss when applicable. Percentages must total 100% for primary beneficiaries.

Relationship:    Percentage:

Relationship:    Percentage:

Claims & Loss Reporting (Notice)

The insured must provide prompt notice to the insurer of any loss or potential claim. Notice must include the date of loss, a brief description of the event, and an estimate of damage. Failure to provide timely notice may prejudice coverage. The insurer may require proofs of loss, inventories of damaged property, and inspections prior to payment.

Agent / Broker Information

Agency:    License No.:    Phone:

Declarations and Certifications

I declare that the information in this application is true and complete. I understand that the issuance of a policy will be subject to verification of facts, underwriting approval, and payment of premium. I understand that the insurer may rescind the policy or deny a claim for material misrepresentation or intentional concealment of relevant facts.

I authorize the insurer and its representatives to obtain and verify information necessary for underwriting and claims handling, including property condition, prior claim history, and credit information where permitted by law. I understand that coverage is subject to terms, conditions, exclusions, and limits set forth in the policy contract.

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