NOKNOWNLOSSSTATEMENT
DATE:____________________________
Insured:__________________________ __________________________________________________
Locationforwhichcoverageisrequested:_________________________________________________
_________________________________________________
I attest that there has not been more than one flood loss within the past five years or any single flood
loss to the structure of $250,000 or greater.
Thereisnounrepairedorstructuraldamagetothepropertywherecoverageisrequestedduetoflood.
Additionally, I agree to notify you in the event a loss occurs between now and the premium receipt date.
I understand that this policy is not intended to cover losses prior to the inception date of the policy or
the premium receipt date, whichever is later.
________________________________ ____________________________
InsuredSignature Date
FraudWarning
Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilean
applicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationorconceals
forthepurposeofmisleadinginformationconcerninganyfactmaterialtheretocommitsafraudulent
insuranceact,whichisacrimeandsubjectsuchapersontocriminalandcivilpenalties.