Insurance Wind Mitigation Protection Form

Insurance Wind Mitigation Protection Form

Applicant / Insured Information

Applicant Name:

Policy Details

Insurer / Company Name:

Policy Period: From to

Wind Mitigation Coverage and Credits

Select mitigation features present at the insured property. Each item may affect underwriting, applicable credits, or deductible adjustments.

Inspection & Documentation

Inspector Name:

Exclusions, Limitations & Conditions

The presence of wind mitigation measures does not expand coverage beyond the terms, limits, and exclusions of the underlying policy. Coverage for wind-related loss remains subject to the policy’s named perils, deductible provisions, and any hurricane or windstorm sub-limits. Insurer retains the right to deny mitigation credit or deny claim coverage if inspections or documentation reveal misrepresentation, improper installation, material defects, lack of maintenance, or alterations inconsistent with the representations herein.

The applicant acknowledges that earned premium credits and deductible reductions offered in connection with mitigation features are contingent on verification by an authorized inspector. Any subsequent discovery of falsified documentation, removal of mitigation components, or modifications that materially diminish the effectiveness of installed measures may result in premium adjustment, rescission of credit, or denial of claim payments to the extent permitted by law.

Beneficiary Designation (if applicable)

Beneficiary Name:

Declaration, Authorization & Certification

I, the undersigned applicant, declare under penalty of perjury that all information provided in this Wind Mitigation Protection Form is true, complete, and accurate to the best of my knowledge. I certify that any mitigation measures reported were installed in substantial compliance with applicable building codes, manufacturer specifications, and industry standards unless otherwise noted. I understand that the insurer may rely on this information in underwriting the policy and determining any premium credits, deductible adjustments, or coverage endorsements.

I authorize the insurer and its authorized representatives to inspect the described property, verify installation documentation, and obtain records from contractors, suppliers, or permitting authorities as necessary to confirm eligibility for mitigation credits or coverage adjustments. I agree to provide access and cooperation for such inspections and to furnish copies of invoices, permits, and certification documents upon request.

I understand that willful misrepresentation or omission of material facts may result in denial of claims, rescission of policy provisions relating to mitigation credits, premium recalculation, or other remedies available to the insurer under contract or law.

Inspector / Contractor Information (if installation performed)

Acknowledgment and Signature

By signing below, the applicant acknowledges that they have read and understand the statements, conditions, and authorizations contained in this form and certify that the information provided is accurate and complete.

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