/ 500 S. Dixie Hwy, Suite 220
Coral Gables, Florida33146
Phone: (888) 774-9977 Fax: (305) 774-6363
CBRA FLOOD APPLICATION
Agency Name: / Agency Code:
Effective Date: / New Application / Renewal Of:
Insured’s Name:
Mailing Address:
Property Address:
(if different from above)
Current Homeowner Carrier:
Name of LOCAL Contact for Inspection: / Phone:
1st Mortgagee:
Loan Number:
Mailing Address:
2nd Mortgagee:
Loan Number:
Mailing Address:
UNDERWRITING INFORMATION:
Occupancy:
Single Family / Primary Residence / 2nd Residency
Tenant Occupied / Vacant / Seasonal
Condo Association / OfficeBuilding / Hotel/Motel
Other:
Construction:
Residential / Non-Residential / Fire Resistive
Masonry / Frame
Basement: / Finished / Unfinished / None
Enclosure: / Yes / No / # of Stories:
Foundation:
Slab / Pilings / Type of Pilings: / Wood / Concrete / Driven / Poured
Building Elevated:
Yes / No / Year Built: / NFIP Flood Zone:
Base Flood Elevation: / Lowest Floor Elevation:
Elevation Difference:
Replacement Cost of Building:
Distance to water within 1000 FT? / Is Property Waterfront?
Loss History:
Any losses in the last 5 years? / Yes / No
Amount of loss: / Date of Loss:
Who to contact for inspection: / Phone No.:
Coverage / Amount
Building:
Contents:
Loss of Income:
Additional Living Expenses:
Fair Rental Value:
25% MINIMUM EARNED PREMIUM
$500.00 MINIMUM PREMIUM
LOSS OF INCOME: 15 DAYS WAITING PERIOD
ADDITIONAL LIVING EXPENSES: 15 DAYS WAITING PERIOD
FAIR RENTAL VALUE: 15 DAYS WAITING PERIOD
NOTE: The insured applicant warrants the truthfulness of its information which will be material in the event of a claim. Any misrepresentation and concealment herein will void all coverage.
Insured Signature: / Date:
Producer Name: / (Printed):
License No:
Building Information:
  1. Please complete the Elevation Data below:

Building Diagram # / Lowest Floor Elevation:
Base Flood Elevation: / Elevation Difference:
Is Building Flood Proofed? / Yes / No / Lowest Adjacent Grade(LAG):
  1. Distance from nearest ocean/gulf/river/lake:

Name of ocean/gulf/river/lake:
0 to 1 mile / 1.1 to 2 miles / 2.1 to 5 miles / 5.1 to 10 miles / Over 10 miles
  1. Is the insured property owned by state government?
/ Yes / No
Is building substantially improved? / Yes / No / If No, explain:
  1. Is building in course of construction?
/ Yes / No
  1. Is building the insured’s seasonal/secondary residence?
/ Yes / No
If Yes, provide the name of the person responsible for securing the property in the event of a storm while the property is unoccupied:
Name: / Telephone No.:
  1. Is building elevated (includes crawl space buildings)?
/ Yes / No
  1. Is the area below the elevated floor enclosed?
/ Yes / No
Type of enclosure walls: / Breakaway / Lattice / Solid perimeter
Other (desc.)
  1. Basement/Garage or enclosed area:
/ None / Finished / Unfinished
  1. Basement/Garage or enclosed area is used for:

Parking/Storage/Access / Other (desc.)
  1. Does basement or enclosed area contain machinery & equipment?
/ Yes / No
  1. Is the lowest floor living area off ground by means of:

Piles / Columns / Solid Walls / Shear Walls / Other
  1. Elevator?
/ Yes / No / Storm Shutters? / Yes / No
  1. Number of floors in entire building (including basement/enclosed area, if any) or building type:

1 / 2 / 3 or more / Split-level / Townhouse/Rowhouse / Condominium
NOTE: THERE IS LIMITED COVERAGE BELOW THE LOWEST ELEVATED FLOOR.
Condominium only:
Total # units (include non-res):
Type: / High-rise / Low-rise
Coverage is for: / Individual Unit / Entire building

SCU 02172017 CFA