Deductible *

Applies separately to building and contents What is a deductible? A deductible is a predetermined amount of money that the insured must pay before a claim is paid. The deductible is applied separately to building coverage and contents coverage.

$2000

$5000

Purchase Requirement *

Loan Closing

Expiring FEMA Policy

Lapsed FEMA Flood Policy

Other-14 Day Waiting Period

Purchase Requirement Date *

Please enter your loan closing date or the date of your expired or expiring flood insurance policy. If you have selected “Other – 14 Day Waiting Period,” please enter 00/00/0000. Your purchase requirement date cannot be more than 75 days after the date of application (today). The 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 within the 30 day grace period (in which case a no known loss statement will be required, click here).

NO COVERAGE IS BOUND UNTIL THE APPLICATION IS APPROVED BY UNDERWRITER AND THE FULL ANNUAL PREMIUM IS RECEIVED.

MM

DD

YYYY

Insured Phone *

Property Owner Phone Numbers (not insurance agent’s phone number)

(###)

###

####

Cell Phone

(###)

###

####

Date of Construction *

MM

DD

YYYY

Number of Floors *

One Floor

Two Floors

Three or More Floors

Occupancy *

Check all that apply.

Non-Residential Building

5 or More Residential Unit Building

Foundation Type *

Slab

Basement Including Walkout

Crawlspace

Other Enclosure

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. *

Yes

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. *

Yes

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. *

Yes

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. *

Yes

No

I understand 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 *

Yes

No

Applicant attests the building does NOT reside in an NFIP community under NFIP probation. The building is NOT located in a Coastal Barrier Resources System (CBRA zone) or an Otherwise Protected Area (OPA). 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). *

Yes

No

Payor of INITIAL policy Term

Who will be paying for this year's policy?

Insured

Lender