Insurance Water Damage Exclusion Form

INSURANCE WATER DAMAGE EXCLUSION FORM

Insured and Policy Information

Policy Details

Policy Period: Effective  to 

Water Damage Coverage Election

The undersigned insured selects one of the following options regarding coverage for water damage arising from the causes described in the Exclusions section below. Selection is made by marking the applicable checkbox. Initials adjacent to each option confirm that the insured has read and acknowledged that selection.

I elect to have the insurer apply a Water Damage Exclusion endorsement to the policy described above, thereby excluding coverage for the specified water perils listed in this form.   Initials:

I decline the Water Damage Exclusion and wish to retain existing water-related coverage as provided by my policy (or obtain the optional endorsement if available).   Initials:

I request a separate Water Damage Endorsement that provides coverage for certain water perils subject to additional premium and specific terms. I understand that issuance of such an endorsement is subject to underwriting and an additional charge.   Initials:

Exclusions — Specific Water Perils

By electing the Water Damage Exclusion, the insured understands and agrees that the insurer will not be liable for loss, damage, expense or liability directly or indirectly caused by, resulting from, contributed to, or aggravated by any of the following water perils (the "Excluded Perils"):

1. Flood: inundation or rise of external surface water, storm surge, tidal wave, surface water, or overflow of a natural body of water.
2. Sewer, Drain or Waste Water Backup: backflow, backup, overflow or discharge of sewage, septic systems, drains or sanitary plumbing systems, unless a specific backup endorsement is separately purchased and attached.
3. Groundwater, Hydrostatic Pressure and Seepage: subsurface water, seepage, hydrostatic pressure, or water rising from the ground and entering the insured premises.
4. Continuous or Repeated Leakage: loss or damage resulting from ongoing or repeated leakage, seepage or moisture over time, including resulting mold, mildew or microbiological growth.
5. Sump Pump and Drainage Failure: failure, stoppage, or insufficient capacity of sump pumps, failing drainage systems, or groundwater controls unless a specific coverage endorsement is purchased and made part of the policy.
6. Construction, Design or Maintenance Defects: water intrusion due to faulty design, construction, installation, or inadequate maintenance of the building, its systems, or appliances.

These exclusions apply regardless of any contributing cause or event that preceded, coincided with, or followed the excluded peril, unless otherwise expressly provided by a written endorsement attached to the policy.

Insured Obligations and Conditions

The insured acknowledges the following conditions that apply to any coverage for water-related loss and to the effect of this exclusion:

• Notification: The insured must provide prompt written notice of any water-related loss in accordance with policy notice provisions.
• Mitigation: The insured shall take all reasonable steps to protect property from further loss following a water event; failure to mitigate may void coverage for resulting damage.
• Proof of Loss and Documentation: The insured must submit adequate documentation including receipts, photos, and repair estimates to support any claim not excluded by this endorsement.
• Inspection and Maintenance: Continued eligibility for any optional water coverage may require proof of inspection and maintenance of plumbing, appliances, and drainage systems.

Reinstatement or Endorsement Optional Terms

Reinstatement of coverage for any of the Excluded Perils may be available by issuance of a separate written endorsement, subject to:

1. Underwriting approval and payment of an additional premium calculated by the insurer;
2. Completion of any required inspections or remedial work to correct identified defects or hazards; and
3. Execution of a written endorsement expressly stating the scope of additional coverage and any applicable limitations, sublimits or deductibles.

Disclosure of Prior Water-Related Losses

Yes    No

Claim Payee / Mortgagee / Beneficiary Information (If Applicable)

If payment on any claim is to be made in whole or part to a mortgagee, loss payee, or other payee, provide the details below. The inclusion of a payee does not alter the scope of the Water Damage Exclusion.

Acknowledgement and Certification

By signing below, the insured certifies that the information provided on this form is true and complete to the best of the insured's knowledge. The insured acknowledges receipt of this Water Damage Exclusion Form, understands the scope and legal effect of the exclusions listed herein, and consents to the application of such exclusion to the policy if the election box has been marked.

The insured understands that this form amends the contract of insurance only as specified by the insurer's endorsement language. The insured further acknowledges that separate endorsements to provide coverage for any excluded peril may be available upon request and subject to underwriting approval and additional premium.

Additional Notices

This Exclusion Form is a contractual notice executed contemporaneously with or prior to application of the exclusion endorsement. It does not replace the policy declarations, which remain controlling except where a written endorsement modifies the policy. The insured is encouraged to review the policy and any attached endorsements carefully to determine the full extent of coverages and exclusions.

Insured Certification

I hereby certify that I have read this Water Damage Exclusion Form and that I understand the exclusions listed within. I acknowledge that choosing the exclusion may reduce the premium but will remove coverage for specified water perils unless a separate endorsement is purchased.

Sign Now