FLOOD INSURANCE APPLICATION
OMS - 026-R-00025
CURRENT POLICY N.UMBER
RENEWAL., FL .,
IF NEW, LEAVE BLANK
.'
.-...... FLOOD INSURANCE
C APPLICATION
g ~1~~~n'l: EMERGENCY AND REGULAR f'ROGRAMS
-~"-" ~~':.':.n~. IMPORTANT -SEE REVERSE SIDE-IMPORTANT
federal emergency managemenl agency 2
NOTE: THE NUMBERED SECTIONS 1-14 CORRESPOND TO INSTRUCTIONS IN THE FLOOD INSURANCE MANUAL
THREE YEAR POLICY CD
P ONE YEAR POLICY I!{]
? 0 DIRECT BILL INSTRUCTIONS:
C
Y BILL I!It1 BILL f21 BILL f3l
T INSUREOru FIRST W SECOND L2J
~ MORTGAGEE MORTGAGEE
M
BILL II]
OTHER
POLICY TERM IS FROM 51 31"4 TO 5 ,31 I 85
MO I DA I YR MO' DA I YR
12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.
IS IT INTENDED THAT THIS POLICY BE EFFECTIVE AT THE TIME
THAT THE DESCRIBED BUILDING IS ACQUIRED? YES [YJ NO lliJ
~b~~ [iJ
PAYEE
A (';:;\3 ADDRESS OF LICENSED PROPERTY O.R CASU.ALTY INSURANCE
~ \.:V AGENT OR BROKER: A 'M 'nSUNlM8 AGency.
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T . P . O. Box 582$
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CLeorltGter. Fl.
(813) 197-4.99
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IF YES. CHECK (if)' GOVERNMENT AGENCY AND ENTER CASE FILE
NUMBER OR INSURED'S SOCIAL SECURITY NUMBER
[iJ I F OTHER, PLEASE SPECI FY II]
N.A~E AND MAILING ADD61=SS OF INS~ED f od
~LeQ~.r ~each >80 0 ,
& ~.~v or CLearwater
37 CousewoyBlvd.
tnc.
33518
~LeQr"'tert Pl.
813) 443-3057
33545
F r,;-.. NAME AND ADDRESS OF FIRST MORTGAGEE
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(';\7 IF SECOND MORTGAGEE, LOSS PAYEE OR OTHER, IS TO BE BILLED.
2 \!..J THE FOLLOWING MUST BE COMPLETED, INCLUDING THE
N NAME AND ADDRESS:
D 2ND MORTGAGEE III LOSS PAYEE [1] DISASTER AGENCY IdJ
~ IF OTHER, PLEASE SPECIFY [iJ
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f8\ IS INSURED PROP~Y LOCATION SAME AS INSURED MAILING
PL \!V ADDRESS? YES rtI NO lliI IF NO, ENTER PROPERTY ADDRESS.
ROlF RURAL. DESCRIBE PROPERTY LOCATION:
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~ 0 NAME OF COUNTY/PARISH? P tn.LLas LOCATED IN AN UNINCORPORATED AREA OF THE COUNTY? YES [YJ NO ~
~ COMMUNITY NUMBER AND SUFFIX FOR LOCATION OF PROPERTY INSURED: 125096
~ COMMUNITY PROGRAM TYPE IS: REGULAR II EMERGENCY ~ IS BUILDING IN SPECIAL FLOOD HAZARD AREA? YES ~ NO lliJ
T FLOOD INSURANCE INFORMATION MAP INFO r.11 COMMUNITY r;;, FLOOD lIt1 r.1
Y RATE MAP ZONE SOURCE: FACILITY LLJ OFFICIAL Ll.J MAP t!!J OTHER Li.J
@ CHECK (if) ONE APPLICABLE BLOCK IN EACH A. B, C,D, E, F, G, AND H BELOW AND COMPLETE I THEN J IF APPLICABLE.
(A) BUILDING OCCUPANCY: (B) BUILDING TYPE .. (C) BAS~T IS: (E) IS PROPERTY A (G) IS THIS BUILDING IN
RESIDENTIAL I(~N~~~?ING BASEMENT NONE CONDOMINIUM? THE COURSE OF
. FINISHED III CONSTRUCTION?
SINGLE FAMILY UJ IJ [1] YES [YJ NO ~ (BUILDERS RISK)
ONE FLOOR UNANISHED
2-4 FAMILY [1] TWO FLOORS [1] YES [YJ NO III
OTHER RESIDENTIAL [iI TH~f~LOORS IdJ
SPLIT LEVEL [iJ (D) INSURED QUALIFIES (F) IS BUILDING OWNED (H) IS BUILDING INSURED'S
NON-RESIDENTIAL IJ AS A SMALL BY STATE PRINCIPAL RESIDENCE?
BUSINESS RISK? GOVERNMENT?
(INCLUDING M~g~~D'i~~O~ ON II] YES [YJ NO ~ iii NO ~ [YJ NO ~
HOTEL/MOTEL) YES YES
(I) ESTIMATED REPLACEMENT COST OF INSURED (J) IF NOT SINGLE FAMILY DWELLING, NUMBER OF OCCUPANCIES:
BUILDING? $60,000 DESCRIBE USES OF BUILDING:
@IS BUILDING MULTIPLE OCCUPANCY? YES [YJ NO ~ IS PERSONAL PROPERTY HOUSEHOLD CONTENTS?
I F YES, INSURED OCCUPIES (CHECK ONE BLOCK BELOW) YES [YJ NO ~
IF NO, PLEASE DESCRIBE BELOW.
BASEMENT ONLY III FIRST FLOOR ONLY iJ equLp..nt
BASEMENT AND ABOVE [1] FIRST FLOOR AND ABOVE ONLY [iJ
SECOND FLOOR AND ABOVE ONLY II]
@ IS BUILDING POST FIRM CONSTRUCTION OR SUBSTANTIAL IMPROVEMENT? YES lYJ NO J(] (SEE REVERSE SIDE FOR DEFINITION.)
IF YES, BUILDING PERMIT DATE OR DATE CONSTRUCTION STARTED, I DA I YR
MO'
IF POST FIRM CONSTRUCTION IN ZONES A1-A30, AH. V1-V30, OR IF PRE FIRM CONSTRUCTION IS ELEVATION RATED, COMPLETE
ELEVATION DATA BELOW:
LOWEST FLOOR ELEVATION (-) BASE FLOOD ELEVATION (=) DIFFERENCE TO NEAREST FOOT (+ OR-)
IS BUILDING FLOOD-PROOFED? YES iii NO lliJ
ATTACH ELEVATION OR FLOOD-PROOFING CERTIFICATION. (SEE FLOOD INSURANCE MANUAL FOR SUGGESTED CERTIFICATE FORM.) FL
IF PREVIOUSLY SUBMITTED, INDICATE POLICY NUMBER TO WHICH CERTIFICATION WAS ATTACHED.
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"'f'ftt1'~.f'nn::.rcr' i
9:9V~~,~,~~9U7'"fED-CH~p~ ONE ~LOCK ~EL~~~,?"RP~~LE,F~.REMAI~D.ER OF SE.~N,13. .
8UILOII"(Hill\D.~",fi;1_i!j:'1fW!,lIIl!llI'd h"<t!~;G)NLV il.: 'loib,I:i! '.
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ADDITiONAL LIMITS
(REGULAR PROGRAM ONLY)
AMOUNT
. OF
ifNSURANCE
BASIC LIMITS
BASIC AND ADDITIONAL
ANNLI~
PREMIUM
.00
.00
.00
.00
TOTAL
PREMIUM
COVERAGE
AMOUNT
OF
INSURANCE
RATE
ANNUAL
PREMIUM
RATE
BUILDING
CONTENTS
BLANKET COVERAGE NOT PERMITTED
(FOR COMPUTATION OF A THREE YEAR PdLICY
ONE YEAR POLICY jJ . MUL TI Pt;X, THE ANNUAL SUBTOTAL BY THREE, AND
THREE YEAR polity [ii' THEN AOEfTHE EXPENSE CONSTANT)
'''''Ii.'
THREE YEAR SUBTOTAL
(ANNUAL X THREE
EXPENSE CONSTANT +
TOTAL PREPAID PREMIUM 0
S t.:i\ THE ABOVE STATEMENTS ARE CORRECT TO
b \!jI BE PUNISHABLE BY FINE DR IMPRISONMENT
N REVERSE HAVE BEEN DISCUSSED WITH INSURED.
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THE BEST OF MY KNOWLEDGE. I LlNDERSTAND THAT ANY FALSE STATEMENTS MAY
UNDER 18 LI.S CODE SEe: 1001. INSURANCE AGENT ALSO CERTIFIES THAT ITEMS ON
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SIGNATURE OF INSURANCE AGENT/BROKER DATE OF APPLICATION
PLEASE ATTACH T.O .NFI." .CQPY,Q...F.'APPLIC.ATlON THE CHECK OR MONEY ORDER F~ THE TOTAL PREPAID
P~~~~~~;~A~~=~L;.QD1~H~~A;~S'AL; ~L~~DIAURA~i~PROGRAM., .',.. _
Attach check to Ori~~~.~:I",a~~.Send to i~\;~4.~r,J!ffl::!~~.~:~.'''I.lIlIIIllliiII.I~MI'';18;lIIOI'tglllee. I / f 0/6 - / I
FEMA 81~16,.(,2-BOl
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FEiRAL EMERGENCY MANAtlMENT AGENCY
FLOOD INSURANCE
APPLICATION
EFFECTIVE DATE. The effective date of this policy must be at least five calendar days
(date of application plus five) after the date of a new application except as noted in the
agent manual.
LOSS IN PROGRESS. The policy does not cover loss resulting from a flood or mudslide
occurrence already in progress on the date of this application. This pOlic:y is subject to the
National Flood Insurance Act of 1968 and any Acts Amendatory thereof, (the Regulations)
issued by the Federal Insurance Administration pursuant to such statutes.
LIMITATIONS OF PERIL. Insurance is provided or,ly (1) against the perii of flood as
defined in the policy, and (2) with respect to those coverages applied for llerein and for
which a specific amount of insurance is shu\'m anj unless otherwise provider! all
conditions and provisions of this form and of the pelicy shall apply separately to Clef,
coverage.
1-4 FAMILY DWELLING Advantages of insuring to value If at the time of Ic:;s tile toLl
amount of insurance applicable to said dwelling is 80 percent or more (If the full
replacement cost of the dwelling, or is the maxi(f;um amount of insurance avaiiable under
the National Flood I nsurance program, the coverage of this policy applicable to such
dwelling is extended to include the full cost cd r"'pair or replacement to the building,
vvithout deduction for depreciation. Further, if tre dwelling is the oVlrner's pr~nc pai
residence the repair costs are extended to inclucc the increased costs necessary to sdtisf;'
Flood Plain Management requirements. These extensions of coverage do not increase tho
stated policy limit. - See General Rules for Mobile Home exception and other explana-
tions.
WARNING
The lnformation requested in Section @ concerning a building erected after DECEMBER
31, 1974 in highly Flood Prone Zones (A1-A30), (AH) or (V1-V30) is MATERIAL to the
Flood Insurance Contract and should have its answers closely examined by the insurance
person submitting the application.
WARNING TO AGENTS AND INSURANCE APPLICANTS. The National Flood Insurance
Act of 1968, as amended, prohibits the payment of flood insurance claims on properties
officially declared to be in violation of Section 1316 of the Act. Therefore, if the lowest
floor elevation of post firm construction or substantial Improvement is below the base flood
elevation for the area, the applicant, for his own protection, should obtain a certification
(e.g. a copy of the variance) from the appropriate community official that the property has
not been officially declared to be in violation of state or local flood plain management
requirements.
POST FIRM CONSTRUCTION OR SUBSTANTIM_ iMPROVEMENT. (Formerly called new
Construction) POST FIRM Construction or :;Jbstantial improvement means. for the
purposes of determining insurance rates, builcin!Js whose construction or substantial
improvement started on or after December 31 1974 or the effective date of the initial
Regular Program. Flood Insurance Rate Map (FIRM) whichever is later Substantial
improvement is any repair. reconstruction, or improvement of a structure, the cost of
which equals or exceeds 500'0 of the market value of the structure.
MORTGAGEE GRACE PERIOD. With respect to any mortgagee (or trustee\ named in this
application, this insurance shall continue in force for the benefit of such m()l"tgCl~Jee (or
trustee) for 30 days after mailing of written notice to the mortgagee (or trustee) of
expiration of this policy. This will provide coverage for approximately 30 daVe, after the
policy expiration in the case of a non-renewal.
NONDISCRIMINATION No person or organization shall be excluded from participating Ill,
denied the benefits of, or subjected to discrimination under the Program authOrIZed by tl:e
Act, on the glounei of race, cc,lor, creelJ,";ux ',j ) natioi-,al or'ni-,
~RUlAC~" :~C,L ..:rh~ informal ion'~" tlelJt!leSted. is n ecesSQry-<il!te~v..pr:;ooeS&t )!OJilJ apo tnSaficf\' ~ ut
f!.')od inSlIr;'.!iC:c. The :'luthority to collect the intormation is Title 42. U.S C>rJG. Secticn
4001 to 4028. It is voluntary on your part to furrc,h the irlformatiol. L '" at ,)8 ,; {:i~'sd
outside the Federal Emergency t\l1anagement Agency except to the serVicing office. acting
as the: government's fiscal agent, to routine users, to your agent and any mortgagee named
on your policy.
National
Flood
Insurance
Program
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