Application Form For Insurance



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IS BUILDING POST-FIRM CONSTRUCTION YES NO BUILDING DIAGRAM NO.: (IF POST-FIRM CONSTRUCTION IN ZONES A, A1–A30, AE, AO, AH, V, V1–V30, VE, OR IF PREFIRM CONSTRUCTION IS ELEVATION RATED, ATTACH ELEVATION CERTIFICATE.) LOWEST FLOOR ELEVATION: IS THE BUILDING A SEVERE REPETITIVE LOSS PROPERTY NO IS BUILDING ELEVATED IF YES, AREA BELOW IS: YES NO FREE OF OBSTRUCTION CONSTRUCTION DATE: / / CHECK ONE OF THE FOLLOWING: BUILDING PERMIT CONSTRUCTION FOR MANUFACTURED (MOBILE) HOMES/ TRAVEL TRAILERS LOCATED OUTSIDE A MOBILE HOME PARK OR SUBDIVISION: DATE OF PERMANENT PLACEMENT NO YES NO NO YES NO WITH OBSTRUCTION / / (=) DIFFERENCE TO NEAREST FOOT: (–) BASE FLOOD ELEVATION: IS BUILDING FLOODPROOFED ESTIMATED BUILDING REPLACEMENT COST YES CONTENTS DEDUCTIBLE (REGULAR PROGRAM ONLY) ANNUAL PREMIUM (+ OR –) NO NO ADDITIONAL LIMITS BASIC LIMITS YES NO (SEE THE NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.) DEDUCTIBLE: BUILDING DEDUCTIBLE BUYBACK YES (INCLUDING FOUNDATION): AMOUNT OF INSURANCE RATE ANNUAL PREMIUM TOTAL PREMIUM PREMIUM REDUCTION/INCREASE BUILDING .00 .00 .00 .00 CONTENTS .00 .00 .00 .00 MANUAL SUBMIT FOR RATE PROVISIONAL RATING C O P Y SUBSTANTIAL IMPROVEMENT FOR MANUFACTURED (MOBILE) HOMES/ TRAVEL TRAILERS LOCATED IN A MOBILE HOME PARK OR SUBDIVISION: CONSTRUCTION DATE OF MOBILE HOME PARK OR SUBDIVISION FACILITIES IN ZONES V AND V1–V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION RATE CATEGORY: N F I P LOWEST ADJACENT GRADE (LAG): ELEVATION CERTIFICATION DATE: RATE YES YES DOES THE BUILDING HAVE ANY ADDITIONS OR EXTENSIONS (ADDITIONS AND EXTENSIONS MAY BE SEPARATELY INSURED.) NO IS PERSONAL PROPERTY HOUSEHOLD CONTENTS YES NO AMOUNT OF INSURANCE OTHER IS BUILDING WALLED AND ROOFED YES NO YES NO IS BUILDING IN THE COURSE OF CONSTRUCTION IS BUILDING OVER WATER NO PARTIALLY ENTIRELY NUMBER OF FLOORS IN BUILDING (INCLUDING BASEMENT/ ENCLOSED AREA, IF ANY) OR BUILDING TYPE 1 2 3 OR MORE SPLIT LEVEL TOWNHOUSE/ROWHOUSE (RCBAP LOW-RISE ONLY) MANUFACTU




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