Lexington Insurance Company
Flood Insurance Application

Today's Date: 06/25/2017
email Effective Date:
Applicant Phone
Co-Applicant Phone
Mailing Address
City/State/Zip
Insured Location (if different than mailing address)
City/State/Zip
Producer Name
Email Address 		Phone Number
Present NFIP/WYO Carrier Policy #
Expiration Date Expiring Premium Is Insurance Required by the Lender Yes No
Within the last 5 years has the applicant had a Foreclosure  Bankruptcy  Repossession 
Prior Carrier/Excess Flood Carrier If prior carrier, cancelled or 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)

REQUESTED LIMITS
Building: Estimated Replacement Cost
$ 		Building Limit Requested
$
Contents: Estimated Cost
$ 		Contents Limit Requested
$

LOSS HISTORY - MUST BE FILLED OUT COMPLETELY
(Include All losses - If more than 2 losses, please attach an additional sheet with specific details for each loss.)
Date Type of Loss Cause Amount Preventative Measures

DWELLING/UNDERWRITING INFORMATION
County #
Community Panel #
Located in Special Flood Hazard Area:
Yes No 		Flood Zone
Pre-Firm Post-Firm Emergency Program?
Yes No 		Date entered
Elevation Difference
(+/- BFE)
Construction Type Frame/Stucco/EIFS Brick/Stone/Masonry Superior
Occupancy Type Primary Secondary Rental Secondary Rental Builders Risk
Number of Families Single Family 2-4 Family
Is one of the units occupied by the insured? Yes No 		Year Built
Year Purchased
Square Footage
Description of the Lowest Floor Basement Yes No
Foundation Type
Concrete Slab Concrete Block Pilings/Stilts 		Enclosure Yes No
Building Elevated
Yes No 		Breakaway Walls
Yes No 		Obstruction
Yes No 		Building Diagram # (if available)
Distance to Ocean/Bay Gulf/River/Other Source of Flooding:  Feet  Miles
Maximum Underlying Limits Carried
Yes No 		Number of Floors(Incl. Basement)
Condominum Unit Floor #
NFIP/WYO Program
Regular Preferred 		Basement of Enclosed Area Below an Elevated Building
Finished Unfinished
Contents Located in:
Basement/Enclosure Basement/Enclosure and Above Lowest Floor Above Ground Level Lowest Floor Above Ground Level & Higher

Maximum Available Underlying Limits Must Be Carried At All Times During the Policy

Additional Underwriting Information
Elevating foundation of the building is:
Piers, posts or pilings Yes No
Reinforced concrete shear walls Yes No
Reinforced masonry piers or concrete piers or columns Yes No
Solid perimeter walls (Note: not approved for elevating in Zones V1-V30, VE or V) Yes No 		Area below the elevated floor:
Is the area below the elevated floor enclosed Yes No
If Yes, check one of the below
Partially Fully
If enclosed, provide size of enclosed area: Sq/ft
Is the area below the elevated floor enclosed using materials other than insect screening or light wood lattice? Yes No
If yes, check one of the following Breakaway walls Solid wood frame walls Masonry walls Other
Is the enclosed area/crawl space for any purpose other than solely for parking of vehicles, building access or storage? Yes No
If yes, describe 		Is the enclosed area/crawl space constructed with openings (excluding doors) to allow the passage of flood waters through the enclosed area? (A zones only)
Yes No
If Yes, provide the number of permanent openings (flood vents within 1 ft. above grade)
Total Area of all permanent openings (flood vents): sq in.

OPTIONAL COVERAGES/ENDORSEMENTS
Coverage Extension for Secondary Homes (Excess Flood only) Yes No
(Provides RCV settlement for building) 		Additional Living Expense (NPC, CoBRA & Emergency only) Yes No
Loss of Rents (Excess Flood only) Yes No

Additional Information/Comments

In order to bind coverage the following must accompany this application:
1. Net Premium 4. Diligent Effort Form
2. Copy of Flood Quote 5. Elevation Certificate
3. Copy of current NFIP/WYO Declaration Page as applicable 6. Property Inspection Contact
Name: Phone:

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."

IMPORTANT ADDITIONAL NOTICE: 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: ______________________

Validation Code: 17108
Enter Validation Code:  (Required)

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