Excess Flood Application

9150 S.W. 87th Avenue, Suite 200, Miami, FL 33176

888-386-9488 / Fax: 305-270-0327

www.WNCFirst.com

EXCESS FLOOD APPLICATION

Applicant/Insured: ______

Mailing Address: ______

City: ______State: ______Zip Code: ______

Property Address (if different): ______

City: ______State: ______Zip Code: ______

First Mortgagee: ______Loan No. ______

Address: ______

City: ______State: ______Zip Code: ______

Second Mortgagee: ______Loan No. ______

Address: ______

City: ______State: ______Zip Code: ______

Agency Name: ______

Address: ______

City: ______State: ______Zip Code: ______

Telephone No.: ______Fax No..: ______

Current Homeowner Carrier: ______Policy No.: ______

Current Excess Flood Company: ______Policy No.: ______

UNDERWRITING INFORMATION

OCCUPANCY: Single Family _____ Primary _____ Secondary Residence _____ Tenant Occupied _____ Vacant _____

# Condo Units _____ Condo Assoc. _____ Office Bldg. _____ Hotel/Motel _____ Other ______Builder Risk____

CONSTRUCTION: Residential ______Non-residential ______Fire Resistive ______Masonry ______Frame ______

# Stories ____ Basement: Finished ____ Unfinished ____ None ____ Enclosure: Yes ____ No ____ Post-FIRM ____ Pre-FIRM ____

FOUNDATION: Slab _____ Pilings _____ Type of Pilings: Wood _____ Concrete _____ Driven _____ Poured _____

Building Elevated: Yes ______No ______Year Built: ______NFIP Flood Zone: ______

Base Flood Elevation: ______Lowest Floor Elevation: ______Elevation Difference: ______

REPLACEMENT COST OF BUILDING: ______

Distance to Water: Property within 1,000 feet of water? Yes ____ No ____ If Yes, is risk waterfront property? Yes ____ No ____

Any portion of the Building Situated over water? Yes______No______

Any prior flood losses? Yes _____ No _____ Amount of Loss: $______Date of Loss: _____/_____/_____

Who to contact for inspection: ______Phone No.: ______

REQUESTED COVERAGE AMOUNT RATE PREMIUM

BUILDING: ______$______

CONTENTS: ______$______

Sub-total $______

Policy Fee $______

Inspection Fee $______

Tax $______

Additional Fee $______

TOTAL $______

Requested Date of Coverage: / /

Note: The Applicant/Insured warrants the truthfulness of the information on this application. Any misrepresentation and/or concealment herein will void all coverage.

[Important: Primary policy declaration page must be submitted with this application]

Applicant/Insured Signature: ______Date: ______/______/______

Producer Signature: ______License # ______Date: ______/______/______

01/07