500 S. Dixie Hwy
Suite 220
Coral Gables, Florida 33146
Phone: (888) 774-9977 Fax: (305) 774-6363
EXCESS FLOOD RENEWAL APPLICATION
Agency Name:
Code:
Renewal Effective Date:
Expiring Policy:
Insured’s Name:
Mailing Address:
(If Different)
1st Mortgagee:
Loan Number:
Mailing Address:
2nd Mortgagee:
Loan Number:
Mailing Address:
PLEASE ATTACH A COPY OF THE MOST RECENT PRIMARY FLOOD POLICY OR APPLICATION
UNDERWRITING INFORMATION REQUIRED:
Any Flood Losses in the last 10 years?
Amount Of Loss:
Date Of Loss:
Distance to water within 1000 FT?
Building Replacement Cost:
Coverage:
Is Property Waterfront?
Flood Zone:
Amount
Rates
Premium
Building:
$0.00
Contents:
$0.00
Loss Of Income:
Additional Living
Expenses:
Fair Rental Value:
$0.00
$0.00
$0.00
Total:
$0.00
SCU 090911 EFA
Policy Fee:
$35.00
$500.00 MINIMUM PREMIUM
Inspection Fee:
$100.00
LOSS OF INCOME: 15 DAYS WAITING PERIOD
Terrorism Fee:
25% MINIMUM EARNED PREMIUM
ADDITIONAL LIVING EXPENSES: 15 DAYS
WAITING PERIOD
FAIR RENTAL VALUE: 15 DAYS WAITING
PERIOD
Tax:
$31.75
Service Fee:
$0.27
CPIC Assessment Fee:
$6.35
FHCF Assessment Fee:
$8.26
Total Annual Premium:
$182.00
NOTE: The insured applicant warrants the truthfulness of its information which will be material in
the event of a claim. Any misrepresentation and concealment herein will void all coverage.
Insured Signature:
Date:
Producer Name:
(Printed):
License No:
16-42 Pursuant to Section 817.234 F.S., Florida Statutes, “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”.
SCU 090911 EFA