ACORD FLOOD INSURANCE APPLICATION

1 FLOOD INSURANCE APPLICATIONCONSTRUCTION AND COMMUNITY INFORMATIONCOVERAGE AND RATING (One building per policy - blanket coverage not permitted)PLEASE ATTACH TO NFIP COPY OF APP CHECK OR MONEY ORDER FOR THE TOTAL PREPAID AMOUNTACORD 301 (3/97)acOACORD CORPORATION 1996 PRODUCERPHONE(A/C, No, Ext):POLICY TYPEINSURANCE COMPANY NAMESTANDARD POLICYRCBAPSCHEDULED BUILDINGMPPPCURRENT POLICY #FLNEWRNWL1 YR3 YRSAGENT STAX IDSOCIAL SECURITY #INSURED S NAME, PHONE #AND MAILING ADDRESSSOC SEC #:IS INSURANCE REQUIRED FOR DISASTER ASSISTANCE?YESNOIF YES:1. SBA2. FEMA3. FMHA4. OTHER (SPECIFY):CASE NUMBER OR SOCIAL SECURITY #:DIRECT BILL TOINSUREDFIRST MORTGAGEESECOND MTGEELOSS PAYEEOTHERWAITING PERIOD:STANDARD 30-DAYINITIAL PURCHASE OF FLOOD INS RELATED TO:LOAN-NO WAITINGMAP REV (ZONE CHANGE FROMNON-SFHA TO SFHA)-- ONE DAYPOLICY EFF DATEPOLICY EXP DATE12:01 LOCAL TIMEAT THE INSURED PROPERTY LOCATIONPROPERTY LOCATIONIS INSURED PROPERTY LOCATION SAME AS INSURED MAILING ADDRESS?

2 YESNOIF NO, ENTER PROPERTY ADDRESS. IF RURAL, DESCRIBE PROPERTY LOCATION(DO NOT USE BOX)FIRST MORTGAGEE S NAME, TELEPHONE NUMBER AND ADDRESSLOAN NUMBER:IF SECOND MORTGAGEE, LOSS PAYEEOR OTHER IS TO BE BILLED, THEFOLLOWING MUST BE COMPLETED:SECOND MORTGAGEE OR OTHERSECOND MORTGAGEELOSS PAYEEDISASTER AGENCYOTHER (SPECIFY)LOAN NUMBER:COUNTY/PARISHCOMM #PANEL #SUFFIXLOC IN UNINCORP AREA OF COUNTY?YESNOIS INSURED PROP OWNED BY STATE GOV?YESNOFLOOD ZONEMONTH & YEAR BUILT/SUBSTANTIAL IMPROVEMENT DATEIS BUILDING SUBSTANTIALLY IMPROVED?YESNOIS BLDG IN COURSE OF CONSTRUCTION?YESNOBUILDING OCCUPANCYSINGLEFAMILY2 - 4 FAMILYOTHERRESIDENTIALIS BLDG PRINCI-PAL RESIDENCE?YESNONONRES (INCHOTEL/MOTEL)RCBAP ONLYTOTAL # UNITS(INCLUDE NON-RES)HIGH-RISELOW-RISECONDO COVERAGE IS FOR:UNITENTIRE BUILDING# FLOORS IN ENTIRE BLDG(INC BASEMENT/ENCLOSEDAREA, IF ANY) OR BLDG TYPE123 OR MORESPLIT-LEVELTOWNHOUSE/ROWHOUSE(RCBAP LOWRISE ONLY)MANUFACTURED MOBILEHOME ON FOUNDATIONMANUFACTURED/MOBILE HOME ONLY:YEAR/MAKE/MODEL:SERIAL NUMBER:WIDTHLENIS HOMEA DOUBLEWIDE?

3 YESNOIS HOMEPROPERLY ANCHORED?YESNOBASEMENT BELOW GRND ON ALL SIDES?NONEFINISHEDUNFINISHEDIS THERE EQUIPMENT (FURNACE, AIR CONDITIONER, HEAT PUMP,HOT WATER HEATER, ETC) IN THE BASEMENT OR ATTACHED GARAGE?YESNOIS BUILDING ELEVATED (INCLUDES CRAWL SPACE BUILDINGS)?YESNOLOWEST FLOOR WHICH INCLUDES LIVING AREA IS OFF GROUND BY MEANS OF:PILESPOSTSPIERSCOLUMNSSOLID PERIMETER WALLSPARALLEL SHEAR WALLSOTHERDOES AREA BELOW ELEVATED FLOOR CONTAIN MACHINERY & EQPT?YESNOIS THERE A WASHER, DRYER OR FOOD FREEZER?YESNONOTE: THERE IS LIMITED COV BELOW THE LOWEST ELEV FLOOR - REVIEW THE POLICYIS THE AREA BELOW THE ELEVATED FLOOR ENCLOSED?YESNOSOLID PERIMETER WITH OPENINGS ACCORDING TO CODE, SUCHAS VENTS (GARAGE DOORS ARE NOT PERMANENT OPENINGS)YESNOAREA IS:FINISHED (20 OR MORE LINEARFEET OF FINISHED WALLS)UNFINISHEDSQ FT AREAENCLOSURE# FEET ELEVATEDFLR ABOVE GRNDTYPE OF ENCLOSURE WALLSBREAK-AWAYLATTICESOLIDPERIMETEROTHE R(DESC):AREA IS USED FORPARKING/STOR-AGE/ACCESSOTHER(DESC):ES TIMATED REPLACEMENT COST, SINGLEFAM PRIN RES, RCBAP & ALL V-ZONE BLDGS$LOCATION OF CONTENTS OWNED BY APPLICANTBASEMENT ONLY (LIMITED COV)BASEMENT & ABOVELOWEST FLOOR ONLY -ABOVE GROUND LEVELLOWEST FLOOR ABOVE GROUND LEVEL& HIGHER FLOORSABOVE GROUND LEVELONE FULL FLOOR OR MOREMANUFACTURED/MOBILE HOMEARE CONTENTS HOUSEHOLD PERSONAL PROPERTY?

4 YESNOCONTENTS OTHER THAN HOUSEHOLD PERSONAL PROPERTYIF POST-FIRM CONSTRUCTION IN ZONES A, A1-A30, AE, AO, AH, V, V1-V30, VE, OR IF PRE-FIRM CONSTRUCTION ISELEVATION-RATED, SUBMIT ELEVATION CERTIFICATION AND COMPLETE THE ELEVATION DATA BELOW:(CERTIFICATE IS OPTIONAL FOR NON-BASEMENT BUILDINGS IN ZONES A, AO AND AH.)BUILDINGDIAGRAM#LOWEST FLOORELEVATION-BASE FLOODELEVATION=ELEV DIFF (NEAR-EST FOOT +/-)IS BUILDINGFLOOD PROOFED?YESNOLOWEST ADJGRADE (LAG)COVERAGETOTAL AMOUNTOF INSURANCEBASIC LIMITSADDITIONAL LIMITS (REG PROGRAM ONLY)DED DISCAMOUNT OFINSURANCERATEANNUALPREMIUMAMOUNT OFINSURANCERATEANNUALPREMIUMANNUAL :BUILDING$CONTENTS$RATE TYPE1. MANUAL2. SUBMIT3. ALTERNATIVE4. V-ZONE RISK FACTOR5. MPPP6. PROV RATINGCOMMUNITY RATING CLASSPAYMENT OPTIONCREDIT CARDOTHERANNUAL SUBTOTALICC PREMIUMSUBTOTALCOMM RATING SYSTEM DISCOUNTSUBTOTAL3 YEAR SUBTOTALPROBATION SURCHARGEEXPENSE CONSTANTFED POLICY FEETOTAL PREPAID AMOUNTTHE ABOVE STATEMENTS ARE CORRECT TO THE BESTOF MY KNOWLEDGE.

5 I UNDERSTAND THAT ANY FALSESTATEMENTS MAY BE PUNISHABLE BY FINE ORIMPRISONMENT UNDER APPLICABLE FEDERAL OF INSURANCE AGENT/BROKERDATE (MM/DD/YY)ACORDTM