Flood Insurance Selection/Rejection Form

Complete this form to select or reject flood insurance coverages.

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  • What is your first name? *
  • What is your last name? *
  • What is your email address? *
  • What is your phone number? *
  • Please enter the full name(s) of the applicant/named insured(s). *
  • IMPORTANT NOTICE

    IMPORTANT NOTICE

    Flood insurance is available under the National Flood Insurance Program (NFIP) in thousands of communities nationwide. It provides coverage for residential and non-residential buildings and their contents, in both high risk as well as low risk areas. Historically, about one quarter of all losses under the NFIP are in low risk areas.

    Flooding is the largest single cause of natural disaster loss and damage in our country. The standard homeowners, dwelling or commercial property insurance policy typically excludes or does not otherwise provide coverage for flood damage. Purchasing separate flood insurance coverage will allow covered flood losses to be adjusted in a similar manner as losses from other perils in other property policies.

    The Federal Emergency Management Agency (FEMA) advises that although federal disaster relief assistance is sometimes available after a flood, such financial assistance is typically in the form of a loan and must be repaid to the Government in addition to any other outstanding loans.

    To the extent that NFIP and/or alternative market flood insurance is available for the property, as your insurance representative, we strongly recommend that you purchase flood insurance.

    SELECTION / REJECTION OF FLOOD INSURANCE COVERAGE

    I understand that flood insurance coverage, either with NFIP or an alternative market, may be available for the property located at the address below. I understand that not all properties are eligible for NFIP coverage (non-participating community properties or coastal barrier resources system properties) and Loss of Income and/or Additional Living Expense coverage is not currently available from the NFIP. I select or reject coverage as indicated below

    I also understand that my selection / rejection of this coverage will apply to all future renewals, continuations and changes unless I notify you otherwise in writing.

  • Do you accept or reject NFIP building coverage? *
  • Do you accept or reject NFIP contents/personal property coverage? *
  • Do you accept or reject excess building coverage? *
  • Do you accept or reject excess contents/personal property coverage? *
  • Do you accept or reject alternative market primary building coverage? *
  • Do you accept or reject alternative market primary contents coverage? *
  • Do you accept or reject alternative market loss of income or additional living expense coverage? *

  • Applicant/Named Insured Signature

  • The named insured/applicant must sign their name in the space below. *
    Clear Signature
  • Enter the date this form is being signed by the named insured/applicant. *
    MM slash DD slash YYYY
  • Enter the address of the property to which this flood insurance selection/rejection form applies. *

  • Producer Signature

  • The producer must sign their name in the space below. *
    Clear Signature
  • Enter the date this form is being signed by the producer. *
    MM slash DD slash YYYY

  • General Information

  • Enter the agency name. *
  • Enter the agency address. *
  • Enter the carrier name.
  • Enter the NAIC code.
  • Enter the policy number.
  • Enter the policy effective date.
    MM slash DD slash YYYY
  • Enter the agency customer ID.
  • Enter the date of this form instance.
    MM slash DD slash YYYY
  • Please enter any additional remarks in the space below.
  • Click the download button in the upper right corner to download a copy of the completed form before submitting it.
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Nathan Lewkowicz

Nathan is the President of Grober Imbey Insurance agency. Nathan provides overall leadership for the agency and in addition manages many of the largest Insurance carrier relationships.

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