Insurance Wind Declaration

INSURANCE WIND DECLARATION

Insurer Name:    Policy Number:

Applicant / Insured Information

Property Location (Subject to Coverage)

Policy Details

Policy Type:    Coverage Amount: $

Policy Period: From to

Wind Coverage Election and Deductible Options

The insured declares the following selection(s) regarding windstorm and related named-storm coverage. Selections below will govern application of deductibles and coverage for wind-related losses as set forth in the policy.

Exclusions and Policy Conditions Relevant to Wind Loss

The insured acknowledges the following exclusions and conditions apply to wind-related claims unless modified in writing by the insurer:

• Loss or damage caused by wear, deterioration, rust, corrosion, settling or inherent vice is excluded.
• Damage resulting from flood, surface water or storm surge is excluded unless otherwise endorsed.
• Pre-existing damage or damage occurring prior to the effective date of the wind coverage is excluded.
• Loss resulting from inadequate maintenance, faulty workmanship or design is excluded.
• Loss caused by insects, vermin or rodents is excluded.

By initialing below, the insured certifies that they have read and understand the above exclusions and policy conditions applicable to wind losses.

Initials:

Beneficiary / Claim Payee Information (if different from insured)

If claim proceeds are to be paid in whole or part to a third party (mortgagee, lienholder, additional payee), complete the following:

Prior Wind Losses and Documentation

Have you sustained prior wind damage to the property within the last five years?   Yes    No

Documentation provided with this declaration (check all that apply):

Declaration and Certification

I, the undersigned insured, declare under penalty of perjury and policy forfeiture that the information contained in this Insurance Wind Declaration is true, complete and correct to the best of my knowledge. I acknowledge that any material misrepresentation may be grounds for denial of coverage or rescission of the wind coverage selected.

I authorize the insurer and its representatives to inspect the described property for the purpose of underwriting and claims evaluation. I understand that acceptance of this declaration by the insurer constitutes an amendment to the policy only if confirmed in writing by the insurer.

I further acknowledge that, unless otherwise permitted by endorsement, flood, storm surge, earth movement, wear and tear, and intentional acts are excluded from wind coverage, and that a separate deductible may apply to wind or named-storm losses as elected above.

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