NPC / CBRA FLOOD INSURANCE APPLICATION
SOUTHWEST BUSINESS CORPORATION NPC CBRA
INSURANCE APPLICATION
.DOC
P.O.BOX 795027 SAN ANTONIO,TEXAS78279-5027 1-866-679-5782 FAX: 210-477-7789 WWW.SWBCEXCESSFLOOD.COM
NEW POLICY RENEWAL POLICY
Date:
Insured:
Mailing Address:
City: State: Zip:
County:
Property Address (if different):
City: State: Zip:
County:
First Mortgagee:
Loan#:
Address:
City: State: Zip:
Agent
Agency Name:
Contact:
Address:
City: State: Zip:
Phone :( ) Fax:( )
E-mail:
Tax ID#:
Surplus Lines Broker SWBC Other:
Agency Name:
Contact:
Address:
City: State: Zip:
Phone :( ) Fax:( )
Tax ID#:
PLEASE CHECK ALL THAT APPLY:
Residential
: Single Family Primary Residence Commercial: Condo.Bldg. Apt.Bldg.: # of Units:
2-4 Family Secondary Residence Hotel / Motel: # of Units:
Single Condo/Apt unit Tenant Occupied Other:
Flood Zone: Yr. Built: No. of Floors (incl. Basemnt): Pre- OR Post -FIRM: Elev. Difference:
Basement? Y N Elevated Bldg? Y N On pilings? Y N Enclosure Y NSize: sf
Construction: Frame Fire-resistive Masonry Other Use: Garage Access Storage Other
Distance from source of flooding: Describe sour ce of flooding:
Any flood losses? Yes No If YES: Loss Date: Amount of loss:$
Please describe. Include bldg/conts loss amounts:
Please indicate if the property is located in: A Non-participating Community A CBRA Area (CBRA risks are ineligible.)
DESIRED BUILDING COVERAGE LIMIT
BUILDING 100% RCV: $ $
Proposed Effective Date/Renew al Date:
ACCEPTANCE OF THIS APPLICATION DOES NOT BIND THE UNDERWRITERS TO COMPLETE THIS INSURANCE.
This application will be made part of the Insurance Policy. The undersigned warrant the truthfulness of this information, which
will be material in the event of a claim under the policy. Any misrepresentation or concealment herein could void the coverage.
SWBC reserves the right to cancel coverage upon receipt of an unsatisfactory inspection report or any other information rel ating to the
property which does not meet our underwriting requirements.
BROKER SIGNATURE: DATE:
INSURED SIGNATURE: DATE:
