Wind Mitigation Insurance Form

WIND MITIGATION INSURANCE FORM

Applicant / Insured Information

Policy Details

Insurer Name:

Policy Number:

Wind Mitigation Features — Structural

Roof Covering Type (select all that apply):

Roof Deck Attachment (select all that apply):

Roof-to-Wall Connection (select one):

Secondary Water Barrier

Openings & Protective Systems

Opening Protection (select all that apply):

Inspection & Verification

Inspection Type: Self-reported Certified inspector Contractor

Attachments & Documentation Checklist

Please indicate which supporting documents are provided:

Exclusions, Limitations and Acknowledgements

This Wind Mitigation Insurance Form documents the presence or absence of wind-resistant features at the described property. It is a record used for underwriting and premium determination only. This form does not amend, extend, replace, or alter any insurance policy terms, limits, coverages, conditions, or exclusions. Coverage and premium adjustments remain subject to underwriting review and verification by the insurer.

The insurer reserves the right to require additional inspection, testing, or documentation. Any misrepresentation, omission, or falsification of material facts in this form may constitute grounds for denial of mitigation credit, premium adjustment, cancellation, or rescission of the policy, where permitted by law. The applicant acknowledges that pre-existing damage and deferred maintenance are not eligible for mitigation credit.

Interested Party / Mortgagee / Beneficiary (If Applicable)

Certification and Authorization

I certify, under penalty of law, that the information provided in this Wind Mitigation Insurance Form is true, correct and complete to the best of my knowledge. I understand that this information will be relied upon by the insurer for underwriting and premium determination. I authorize the insurer, its representatives, and contractors to inspect the described property and to obtain records, permits, photographs, or other evidence to verify representations made herein.

I further acknowledge that mitigation credits or premium adjustments granted as a consequence of this form are conditional on verification of the stated features and compliance with applicable building codes and industry standards. I understand that submission of this form does not guarantee eligibility for specific discounts and that final determination rests with the insurer.

Sign Now