Excess Flood LEX 13

All fields are required, otherwise enter 'n/a' for not applicable.
Agent Information:
Producing Office:
Producer Name:
E-mail:
Address:
Phone #:
Fax #:
New  Renewal, Prior Policy #:
  Date Coverage Is To Be Effective:
Insured Information:
Name:                  
Mailing Address:
City:  State:  Zip:
Insured Location:
City:  State:  Zip:
County:  Phone Number:
Mortgagee Information/Additional Interests
Loan Number:      
Name:                  
Address:            
City:  State:  Zip:
Property Information:
Is property covered under a Builder's Risk policy?  Y  N 
     If Yes, is it walled and roofed? 
Has applicant had a foreclosure, repossession or bankruptcy
during the past five years? Y  N 
Construction: Masonry  Frame     Year Built 
Breakaway Walls: Y  N 
Distance to Ocean/Bay/Gulf:   Ft.   Miles
Stormshutters: Y  N   If yes, type 






Limits of Policy:
Buildings: Est. Replacement Cost: $ 
  =Building Limit Requested:           $ 
Contents: Est. Replacement Cost: $ 
  =Content Limit Requested:           $ 
Underlying Policy Information
Present NFIP/WYO Carrier:
Policy Term:    Underlying Carrier: 
     Non-Renewed: Y  N   Why? 
Renewal or Replacement NFIP/WYO Carrier:
Policy Term:    Underlying Carrier: 
     Pol #:   Eff. Date: 
Coverage: Bldg.  $   Contents: $ 
Maximum Underlying Limit Carried: Y  N   (Max Required)
NFIP/WYO Program:  Regular  Preferred 
Number of families:    Single  2-4 Family 
Condominium Unit Apartment
Occupancy:            Primary  Secondary   
                             Seasonal   Rental  
Flood Zone:     Number of Floors: 
Pre-Firm   OR Post-Firm  
Dwelling has basement or enclosed foundation:  Y  N  
Elevation Difference:    (+/-BFE)
Contents Location:
             Basement and Above   Enclosure and Above
             Lowest floor only, above ground level
             Lowest floor above ground level and higher floors
             Above ground level - more than one floor

Maximum Available Limits Must Be Carried At All Times During The Policy Term-25% Minimum Earned Premium Applies
Prior Carrier / Flood Related Loss Information
Excess Flood Carrier:  Expires: Premium: $ Non-Renewed:  Y  N 
Reason/Remarks:
Date Amount Details
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 in-force
Name:  Date: 

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I do not have an assigned underwriter
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