Insurance Application Form
Download a blank fillable Insurance Application Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Insurance Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Excess Flood Insurance Application
Underwritten by Certain Underwriters at Lloyd’s of London
SECTION I - APPLICANT
Insured: ___________________________________________________________________________
Mailing address: ____________________________________________________________________
City:___________________________________________________State:________Zip: ___________
Property location: ___________________________________________________________________
City:________________________________County:______________State:_______Zip: ___________
SECTION II - RISK INFORMATION NEEDED TO QUOTE
Occupancy:
❑
❑
❑
❑
Residential
Apartments
Condos
Commercial
If condo, number of units:________
Describe business operations and business personal property:________________________________
__________________________________________________________________________________
Construction type:
❑
❑
❑
❑
Frame
Masonry
Fire Resistive
Other
If other, describe:____________________________________________________________________
Number of floors, including basement:________Year built: _______ Square Feet (ground floor):______
❑
❑
❑
❑
❑
Basement
Slab
Enclosure
Finished
Unfinished
Type of Pilings:
❑
❑
❑
❑
❑
None
Wood
Concrete
Driven
Poured
Name of and distance from closest body of water:__________________________________________
❑
❑
Risk elevated:
Y
N Elevation difference:_________Flood zone: _______________________
Underlying Building Coverage:
❑
❑
❑
❑
$250,000
$250,000 per unit
$500,000
Other
If other, please describe:______________________________________________________________
❑
❑
Flood Losses Past Five Years:
Y
N
If yes, please list:____________________________________________________________________
Page 1 of 3
XS Flood App Rev 4/09
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business