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

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

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File type: PDF

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Primary 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 – Underwriting Information:
Date of Construction:
If Post-FIRM Construction and Zone A or V, elevation certificate must be attached.
Occupation: Single Family: Commercial Residential Duplex/Apartment: # of Units:
Residential – Condominium: # of Units: Commercial – Condominium: # of Units:
If a business, description of operations: ___________________________________________________
Construction Type: Frame: Fire Resistive: Masonry: Other: ____________
Number of floors including basement:
Square footage of lowest floor?
Basement Information:
Basement or
enclosure: Yes
No Finished Unfinished
If yes, are all 4 sides below grade? : Yes No
If yes, are wash through or breakaway walls present? : Yes No
Machinery and equipmen
t within the ba
sement or crawl space?
Furnace or Boiler:
Heat Pump: Air Conditioner: Hot Water Heater:
Oil Tank: Elevator Equipment: Cistern: Other Machinery: ______________________
List total value of machinery & equipment:
Elevated Building:
Is the building elevated? : Yes No If yes, at what height? ft.
If yes: On Pilings: Concrete Piers/Columns: Concrete Shear Walls: Solid Perimeter Walls:
If yes, are wash through or breakaway walls present? : Yes No
Is area below the raised floor enclosed? Yes No If yes size of enclosure in square feet? _______
If yes, is area enclosed with:
Light Wood Lattice: Masonry Walls: Solid Walls: Breakaway Walls: Insect Screening:
NFIP Flood Zone:
DualCommercial
Does Area have flood vents, openings or breakout panels? Yes No
Garage Information:
None Attached Detached Total Square Feet __________
Additional Information:
Is there a mid
-level foyer in the building? Yes No Size of the mid-level foyer? ________
Is mid-level fo
yer used for purposes other than building access? Yes No
Are there elevators below the base flood elevation? Yes No
Number of elevators :
Elevator enclosure material? Please describe
Property Purchase Date ____________ Is policy for: Owner Tenant
Is the intended use of the building for business? Yes No
Is the building a rental property? Yes No
Any prior flood losses? Yes No (If yes, please attach loss run or description of loss)
Distance to closest body of water: Ocean: River: Other:
Section III – Primary Limits Required:
Requested effective Date:
Total insurable values Building replacement cost:$ Contents replacement cost:$
Requested NFIP Limits: Building:$ Contents:$ Deductible:$
Section IV – Mortgagee Information:
Primary mortgagee: _________________ Loan #: _________________________________
Mailing address: __________________________________________________________________
City: ___________________________ State: ______ Zip: ___________________
Section V – 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
DualCommercial
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Primary Flood Insurance Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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