Fillable Excess Flood Insurance Application (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank Excess Flood Insurance Application (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Excess Flood Insurance Application (Risk Placement Services, Inc.)

On average this form takes 18 minutes to complete

The Excess Flood Insurance Application (Risk Placement Services, Inc.) form is 2 pages long and contains:

  • 1 signature
  • 16 check-boxes
  • 59 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
______________________________________________________________________________
Excess Flood Insurance Application
Please read this application carefully and complete all sections.
Section I – Applicant:
Insured:
Mailing Address:
________________________________________________________________________
City: ____________________________ State: _________________ Zip: ______________
Property Location: ______________________________________________________________________
City: _________________ County: _________ State: _________ Zip: ________
Section II –UnderwritingInformation:
NFIP Flood Zone:
Date of Construction:
If Post-FIRM Construction and Zone A or V, elevation certificate must be attached.
Occupation: Single Family:
Residential Duplex/Apartment: # of Units:
Residential – Condominium: # of Units:
Commercial –Condominium: # of Units:
Commercial:
If a business, description of operations: _______________________________________________________
If a business and contents overage is desired please provide a description of contents/inventory and how it is stored:
__________________________________________________________________________________
Construction Type: Frame: Fire Resistive: Masonry : Other:
Number of floors including basement:
Square footage of lowest floor?
Building on driven pilings? Yes No
Bas em ent o r enc l o sur e: Y e s No Finished Unfinished
If yes, are wash through or breakaway walls present? : Yes No
Is
the building elevated?: Yes
No If yes, at what height? ft.
Any flood losses (last 5 yrs.) (If yes, please attach loss run or description of loss)
Distance to closest body of water: Ocean: River: Other:
Total Replacement Coverage Type Value
Cost Values A) Building Replacement Cost Values $ _________
A) Contents Replacement Cost Values $ _________
B) Loss of Income (12 months): $ _________
SectionIII –Excess Limits Required: Requested effective Date:
Building: $
Contents: $
Loss of income: $
Section IV –Underlying Flood Policy Information:
Primary flood carrier: _________________ Current excess flood carrier: ____________________
Policy Number: ______________________ Excess policy number: _________________________
Policy effective date: __________________ Policy effective date: __________________________
Section V –Mortgagee Information:
Primary mortgagee: __________________ Loan #: ___________________________________
Mailing address: _______________________________________________________________________
City: _____________________________ State: ______ Zip: _____________________
Section VI –Notice to Insured:
Note: This application shall become a part of the Certificate. I/We hereby declare that the above statements and
particulars are true, that I/we have not suppressed or misstated any material facts and I/we agree that this Application
form shall be the basis of the Contract with Underwriters.
________________________________________ ___________________________________________
Signature of Applicant (Insured) Date
Section VII –Producer Information:
Broker/Agency Name: __________________________________________________________________
Mailing Address: ______________________________________________________________________
City: ______________________________ State: _____________ Zip: _____________
Contact Person: _____________________ Tele: ______________ Fax: _____________
Surplus Lines Broker Name: _____________________________________________________________
Address: ___________________________________________________________________________
License No: _________________________________________________________________________
A signed application is not required to obtain a quote; however, in order to issue the policy, we must receive the following
documentation:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Excess Flood Insurance Application (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document