Insurance Water Backup Application

INSURANCE WATER BACKUP APPLICATION

Applicant / Insured Information

Date of Birth:   Policyholder (if different):

Property Information

Is there a basement or lower level? Yes     Is there a sump pump on premises? Yes

Policy Details Requested

Requested Policy Period: From to    Estimated Annual Premium:

Coverage Options — Select All That Apply

Sewer backup / overflow from public sewer system

Sump pump overflow or failure

Water entering through floor drains or utility pits

Coverage for mold remediation and clean-up expenses resulting from covered water backup loss

Exclusions and Limitations — Applicant Acknowledgement

Applicant acknowledges that coverage, if bound, will be subject to specific policy exclusions, which commonly include damage caused by natural flooding, surface water rising from outside the building (unless endorsed), gradual seepage, lack of maintenance, willful misconduct, and losses that are otherwise excluded under the primary property policy. Limits, sub-limits, waiting periods, and specific deductibles for water backup coverages will be set forth in the policy endorsements.

Loss History & Risk Mitigation

Have you sustained any water backup or sewer backup loss at the insured premises in the last five years? Yes (If checked, provide details below)

Describe any mitigation measures in place (e.g., backflow preventer, elevated utilities, sump pump with battery backup):

Beneficiary / Payee Designation (If Applicable)

For policies that provide specific payable benefits to a designated payee, provide beneficiary information below. If not applicable, leave blank.

Agent / Broker Information

Declaration and Applicant Certification

I hereby apply for the water backup coverage requested herein. I represent that the answers and statements contained in this application are true and complete to the best of my knowledge. I understand that any material misrepresentation or omission may be grounds for denial of coverage or rescission of the policy. I authorize the insurer to obtain reports and to make such investigations as are necessary to evaluate this application, including prior loss history and inspection reports.

I acknowledge that coverage is subject to policy terms, conditions, limits, endorsements, and exclusions. I acknowledge that no coverage is bound until a policy or endorsement is issued by the insurer and any required premium is paid.

Applicant attests that all information provided in this application is complete and accurate: (check to attest)

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