Deductible
*
Applies separately to building and contents
Purchase Requirement
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Requested Effective Date
*
Cannot be more than 60 days from date of application. Required waiting period is 14 days unless the date of a loan closing is sooner, you have an active FEMA policy, or a FEMA policy unpaid renewal is within the 30 day grace period. (to maintain prior expiration date requires a “no known loss” letter,
click here ).
NO COVERAGE IS BOUND UNTIL THE APPLICATION IS APPROVED BY UNDERWRITER AND THE FULL ANNUAL PREMIUM IS RECEIVED.
MM
DD
YYYY
Company Name
Insured First Name
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Insured Last Name
*
2nd Insured First Name
2nd Insured Last Name
City
*
State
*
AL
AZ
CA
CO
CT
DE
FL
GA
HI
IA
IL
IN
KS
LA
MA
MD
ME
MI
MO
MS
NC
NE
NH
NJ
NM
OH
OK
OR
PA
RI
SC
TX
VA
VT
WA
WI
WV
Zip Code
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County in Which Located
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Mailing Address (if different than property)
Mailing Address City
Mailing Address State
Mailing Address Zip Code
Insured Phone
*
Property Owner Phone Numbers (not insurance agent’s phone number)
(###)
###
####
Cell Phone
(###)
###
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Current flood Insurance Carrier (if any)
Expiration Date of Current Flood Policy
Skip if you don't have a current insurance carrier
MM
DD
YYYY
Date of Construction
*
MM
DD
YYYY
Number of Floors
*
Occupancy
*
Check all that apply.
Foundation Type
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Building Description
*
First Mortgagee Name (if applicable)
First Mortgagee Address
First Mortgagee City
First Mortgagee State
First Mortgagee Zip Code
First Mortgagee Loan Number
Second Mortgagee Name (if applicable)
Second Mortgagee Address
Second Mortgagee Name City
Second Mortgagee Name State
Second Mortgagee Name Zip Code
Second Mortgagee Name Loan Number
In 2014, Congress enacted the Homeowner Flood Insurance Affordability Act, which authorizes the National Flood Insurance Program (NFIP) to make a lower cost flood insurance rating option (known as grandfathering) available to property owners who have participated in the NFIP by maintaining continuous, uninterrupted coverage through NFIP. If you intentionally allow your NFIP policy to lapse and later choose to repurchase a NFIP policy, it is possible that FEMA may apply the full risk rate -- and not the grandfathered lower cost rate -- for flood insurance for this property. Applicant hereby understands and acknowledges that if continuous coverage is not maintained with NFIP, then the subject property might no longer be eligible for a grandfathering discount, and the full risk rate may apply, if at some later date insurance applicant seeks to obtain coverage from the NFIP.
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Applicant attests that they are aware that personal property coverage of up to $500,000 is available and excess flood insurance over $500,000 is available and requires a separate application.
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Applicant attests that they are aware that flood insurance building coverage is available up to $500,000 and excess flood insurance over $500,000 is available and requires a separate application.
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Applicant attests that they are not aware of more than one flood loss within the past five years, unrepaired damage from a flood, a flood loss to the structure of $250,000 or greater, or that the property has been designated by FEMA as a Severe Repetitive Loss property.
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Applicant attests that they are aware that quoted premiums for properties with more than one flood loss within the past five years, properties with unrepaired damage from a flood, and any property that has been designated by FEMA as a Severe Repetitive Loss property are double those premiums quoted for properties without such losses and the policy, if issued, contains provisions for reduction and reformation of coverage if prior flood damage is discovered that has not been disclosed
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Applicant attests the building does not reside in an NFIP community under NFIP probation. Nor has the property been designated by a duly constituted State or local authority to be in violation of State or local floodplain management regulates (Section 1316).
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Comments and/or Any Additional Information:
*
Payor of INITIAL policy Term
Who will be paying for this year's policy?
