Lexington Insurance Company Excess Flood Insurance Application

Applicant(Required)

Phone Number(Required)

Effective Date From

Applicant

Phone Number

Effective Date From

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

Insured Location

Street Address City State / Province / Region ZIP / Postal Code

Producer Name(Required)

Email Address(Required)

Surplus Lines License #

Phone Number

Present NFIP/WYO Carrier

Policy #

Expiration Date

MM slash DD slash YYYY

Expiring Premium

Is Insurance Required by the Lender

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? (MISSOURI APPLICANTS NEED NOT REPLY)

If the insured has not carried insurance within the last 12 months please explain why?

Mortgagee (Name/Mailing Address Including Zip Code)

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

Note: Loss History includes all losses within the last 3 years regardless of location and any loss greater than $1,000,000 regardless of location or date.

Date

Type of Loss

Cause

Amount

Preventative Measures

Date

Type of Loss

Cause

Amount

Preventative Measures

Date

Type of Loss

Cause

Amount

Preventative Measures

DWELLING/UNDERWRITING INFORMATION

County

Community Panel #

Located in Special Flood Hazard Area

Flood Zone

Firm Type

Pre-Firm

Post-Firm

Emergency Program?

(Emergency Program does not qualify for Lexington Flood Program)

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

Year Built

Year Purchased

Square Footage

Description of the Lowest Floor

Basement

Foundation Type:

Concrete Slab

Concrete Block

Pilings/Stilts

Enclosure

Building Elevated

Breakaway Walls

Obstruction

Building Diagram # (if available)

Distance to Ocean/ Bay/ Gulf/ River/Other Source of Flooding (Ft)

Miles

Maximum Underlying Limits Carried

Number of Floors (Incl. Basement)

Condominium Unit Floor #

NFIP/WYO Program

Regular

Preferred

Basement or 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

Elevated Buildings Only Elevating foundation of the building is:

Piers, posts or pilings

Reinforced concrete shear walls

Reinforced masonry piers or concrete piers or columns

Solid perimeter walls (Note: not approved for elevating in Zones V1-V30, VE or V)

- Is the area below the elevated floor enclosed

- If Yes, circle 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?

If yes, circle one of the following:

Breakaway walls

Solid wood frame walls

Masonry walls

Other

Is the enclosed area/crawl space used for any purpose other than solely for parking of vehicles, building access or storage?

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)

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 Coverage

Coverage Extension for Secondary Homes (Excess Flood only) (Provides RCV settlement for building)

Details

Loss of Rents (Excess Flood only)

Details

Additional Living Expense (NPC, CoBRA & Emergency only)

Details

Additional Information / Comments

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

NOTICE TO 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 ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA 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 AUTHORITIES

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 IN 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 MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY 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 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 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, OR 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 (365:15-1-10, 36 §3613.1).

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 TENNESSEE, VIRGINIA AND WASHINGTON 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.

NOTICE TO VERMONT 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE: RISK SPECIALISTS COMPANIES INSURANCE AGENCY, INC., THE SURPLUS LINES INSURANCE BROKER THAT IS SUBMITTING THIS APPLICATION TO LEXINGTON INSURANCE COMPANY (“LEXINGTON”), MAY CHARGE YOU A FEE FOR PLACEMENT OF INSURANCE IN THE EVENT THAT THE INSURANCE YOU ARE REQUESTING IS ACCEPTED BY LEXINGTON. IF LEXINGTON ACCEPTS SUCH INSURANCE, THIS FEE WILL BE STATED IN THE QUOTE, BINDER, AND POLICY. YOUR ACCEPTANCE OF ANY SUCH QUOTE WILL CONSTITUTE YOUR AGREEMENT TO PAY SUCH FEE.

PRODUCER’S SIGNATURE:(Required)

Date(Required)

MM slash DD slash YYYY

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. 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. 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:(Required)

Date(Required)

MM slash DD slash YYYY

File

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Lexington Insurance Company Excess Flood Insurance Application

REQUESTED LIMITS

LOSS HISTORY

DWELLING/UNDERWRITING INFORMATION

Additional Underwriting Information

Optional Coverage

Corporate Headquarters

Mid-Atlanic Office

New England Office

Florida Office