Applicant Information: Name________________________________________
Mailing Address_______________________________
City _____________________State ____Zip________
Phone ____________________ Fax _______________
1st Mortgage Information: Escrowed Y / N
___________________________________________
___________________________________________
City____________________ State____ Zip________
Loan #__________________________
2nd Mortgage Information ___________________________________________
___________________________________________
City____________________ State____ Zip________
Loan #__________________________
FLOOD EXCLUSION
I, (print name) , understand that the premium paid on my Lloyd’s Policy does not cover flood or rising water from the result of any occurrence. Damage from the result of flood is not covered on my home under the Lloyds policy regardless of whether it was blown by wind or not.
Coverage Information:
Form: DP-3 HO-3
Wind and Hail Ded: ____________ AOP Ded:_____________
PREMIUM ____________
FEE ____________
TAX ____________
TOTAL ____________ Requested Effective Date ___________________
By signing I verify I understand the terms and conditions of the insurance for which I am applying.
APPLICANT SIGNATURE _____________________________ DATE ____________