Flood Insurance Selection / Rejection Form

1 Flood Insurance Selection / Rejection FormStandard property policies including but not limited to homeowners policies, dwellingpolicies, or commercial property Insurance policies exclude coverage for flooding events. As your Insurance agency, we strongly recommend that you purchase Flood understand that Flood Insurance coverage is available for the property located at theaddress below. I make the elections or rejections for coverage as indicated below. I alsounderstand that my election and/or Rejection of this coverage will apply to all futurerenewals, continuations, and changes unless I notify my Insurance agency otherwise inwriting.

2 Type of Coverage Accept Reject Building Coverage Contents/Personal Property Excess Building Coverage Excess Contents/Personal Property I hereby certify that I have been offered Flood Insurance Coverage by my Insurance agent,available from the National Flood Insurance Program, and that my agent, and/or the Agencywill be held harmless and not liable in the event I suffer a Flood loss.

3 If any coverage is accepted, you will be required to purchase an additional policy atadditional cost to you for Flood coverage, it is not included automatically in any other signature Date_____ Address of Property_____Agent / CSR Signature Dat