Clearwater Underwriters, Inc.

Excess Flood Application

	Applicant / Insured
Insured: (*)	Invalid Input
Mailing Address: (*)	Invalid Input
City, State Zip (*)	Invalid Input
Property Address (if different):	Invalid Input
City, State Zip	Invalid Input
	Mortgagee
First Mortgagee:	Invalid Input
Loan No:	Invalid Input
Address:	Invalid Input
City, State Zip	Invalid Input
Second Mortgagee:	Invalid Input
Loan No:	Invalid Input
Address:	Invalid Input
City, State Zip:	Invalid Input
	Agent
Agency Name: (*)	Invalid Input
Contact: (*)	Invalid Input
Email Address: (*)	Invalid Input
Address: (*)	Invalid Input
City, State Zip (*)	Invalid Input
Phone Number: (*)	Invalid Input
	Policy Info
Primary Flood Company:	Invalid Input
Policy Number:	Invalid Input
NFIP Building Limits: (*)	Invalid Input
NFIP Contents Limits: (*)	Invalid Input
Current Excess Flood Company:	Invalid Input
Policy Number:	Invalid Input

	Underwriting
Occupancy: (*)	Invalid Input
If you chose Other for Occupancy, please describe:	Invalid Input
If Condo Assoc. how many units:	Invalid Input
Construction (*)	Invalid Input
# of Stories: (*)	Invalid Input
Basement: (*)	Invalid Input
Enclosure:	Invalid Input
Pre or Post-FIRM: (*)	Invalid Input
Foundation: (*)	Invalid Input
Is Building Elevated? (*)	Invalid Input
Year Built: (*)	Invalid Input
NFIP Flood Zone: (*)	Invalid Input
	For Post-FIRM A & V zones, the following elevation info must be completed.
Base Flood Elevation:	Invalid Input
Lowest Floor Elevation:	Invalid Input
Elevation Difference:	Invalid Input
Replacement Cost of Building: (*)	Invalid Input
Replacement Cost of Contents: (If none, put 0) (*)	Invalid Input
Replacement Cost of B. I.: (If none, put 0) (*)	Invalid Input
Is property within 1,000 ft of water? (*)	Invalid Input
Is the risk waterfront property: (*)	Invalid Input
Any portion of the building situated over water: (*)	Invalid Input
Any prior flood losses? (*)	Invalid Input
If you chose yes for prior flood loss, please provide the date and amount.	Invalid Input
	Inspection
Contact name for inspection:	Invalid Input
Contact phone number:	Invalid Input
	Requested Coverage Amount
Building: (*)	Invalid Input
Business Income:	Invalid Input
Contents:	Invalid Input
Requested Date of Coverage:	Invalid Input
Any additional remarks:	Invalid Input
Preferred Underwriter to work this risk: (*)	Invalid Input