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Lexington Insurance Company - Application Excess Flood Program (Risk Placement Services, Inc.)

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EXF APP 07 06
Lexington Insurance Company - Application Excess Flood Program
Applicant SS# Occupation Employer Date of Birth
Mailing Address City/State/Zip County
Insured Location City/ State /Zip County
Producer Name
Email Address
Surplus Lines License # Phone Number
Present NFIP/WYO Carrier Policy #
Expiration Date Expiring Premium Effective Date of this policy
Within the last 5 years has the applicant had a Foreclosure Bankruptcy Repossession
If prior carrier non-renewed, why?
If the insured has not carried insurance within the last 12 months please explain why?
Mortgagee Mailing Address Including Zip Code
Name/Address Loan #
Additional Insured
Name
/Address/City/State/Zip
LOSS HISTORY- MUST BE FILLED OUT COMPLETELY
(Please include ALL losses)
Date
Type of Loss Cause Amount
Preventative Measures
DWELLING INFORMATIO
N
County Te
rritory #
Construction Type Frame/Stucco/ EIFS Brick/Stone/Masonry Superior
Occupancy Type Primary Secondary Rental Secondary Rental Builders Risk
Year Built Year Purchased
Square Footage
Description of the lowest floor Basement Y N
Foundation Type Concrete Slab Concrete Block Pilings/Stilts Enclosure Y N
Building Elevated Y N Breakaway walls Y N Building Diagram # (if available)
Distance to Ocean/ Bay/ Gulf/ River ft. miles
UNDERWRITING
INFORMATION
Maxim
um Underlying Limits Carried Y N
Buildin
g: Est. Replacement Cost $
NFIP/WYO Program Regular Preferred Building Limit Requested $
Number of Families Single Family 2-4 Family Contents Estimated Cost $
Number of Floors Condominium Unit Contents Limit Requested $
Basement Finished Unfinished
Flood Z
one
Pre
Firm OR Post Firm
Elevat
ion Difference (+/-BFE)
Maximum Available Underlying Limits Must Be Carried At All Times During The Policy Term
EXF APP 07 06
Additional Information / Comments
NOTICE OF INSURANCE INFORMATION PRACTICES: Personal information about you may be collected from persons other than you. Such information,
as well as other personal and privileged information, collected by us or your agent may, in certain circumstances, be disclosed to third parties. You have the
right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our
practices regarding such information is available upon request. Contact your agent/broker for instruction on how to submit a request to us.
NOTICE TO ARKANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR
BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES
AND CONFINEMENT IN PRISON.”
NOTICE TO COLORADO APPLICANTS: “IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO
AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES
FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING
TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE
REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.”
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: “WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER
FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN
INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.”
NOTICE TO FLORIDA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE
THIRD DEGREE.”
NOTICE TO KENTUCKY APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.”
NOTICE TO LOUISIANA APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR
BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES
AND CONFINEMENT IN PRISON.”
NOTICE TO MAINE APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.”
NOTICE TO MINNESOTA APPLICANTS: “A PERSON WHO SUBMITS AN APPLICATION OR FILES CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A
FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.”
NOTICE TO NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN
INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”
NOTICE TO NEW MEXICO APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR
BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL
FINES AND CRIMINAL PENALTIES.”
NOTICE TO NEW YORK APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME,
AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH
VIOLATION.”
NOTICE TO OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN
INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.”
NOTICE TO OKLAHOMA APPLICANTS: “WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY
INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS
GUILTY OF A FELONY.”
NOTICE TO PENNSYLVANIA APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES."
NOTICE TO VIRGINIA APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE
BENEFITS.”
NOTICE TO WEST VIRGINIA APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR
BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES
AND CONFINEMENT IN PRISON.”
EXF APP 07 06
IMPORTANT ADDITIONAL NOTICES:
1. This application does not bind the applicant to buy, or the insurer to issue the insurance, but it is agreed that this application shall be
the basis of the insurance policy.
Applicant’s Statement: The undersigned applicant declares that if the information supplied on this application changes between the date
of this application and the time when the insurance policy is issued, the applicant will immediately notify the insurer of such changes, and
the insurer may withdraw or modify any outstanding quotations and/or authorizations or agreement to bind this insurance.
The undersigned applicant further declares that I have read and understand the entire application including the applicable fraud warning, if
any, and that the statements set forth in this application are true and complete.
APPLICANT’S SIGNATURE: _______________________________________ DATE: ________________________________
PRODUCER’S SIGNATURE: _______________________________________ DATE: ________________________________
In order to bind coverage the following must accompany this application:
1. Net Premium 5. Diligent Effort Form
2. Copy of Excess Flood Quote 6. Elevation Certificate
3. Copy of Current NFIP/WYO Declaration Page 7. Property Inspection Contact
4. Evidence of Wind Coverage Name: Phone #
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Lexington Insurance Company - Application Excess Flood Program (Risk Placement Services, Inc.)

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Completed 30 July 2020

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