Form Wh0005 - Certificate Of Essential Property Insurance - North Carolina Insurance Underwriting Association

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NORTH CAROLINA INSURANCE UNDERWRITING ASSOCIATION
CERTIFICATE OF ESSENTIAL PROPERTY INSURANCE
(Applicable to Beach and Coastal Areas)
A COPY OF THE ESSENTIAL PROPERTY DECLARATIONS, AN ACORD CERTIFICATE OF INSURANCE
OR THIS CERTIFICATE MUST BE SUBMITTED TO APPLY FOR WINDSTORM & HAIL INSURANCE
The North Carolina Insurance Underwriting Association cannot, by law, provide Windstorm & Hail insurance unless it is provided a
certificate, properly completed and signed, that Essential Property Insurance {as defined by G.S. 58-45-35(e)}, written by a licensed
insurer, is in force. “Essential Property Insurance ", as defined by G.S. 58-45-5(4), means insurance against direct loss to property as
defined in the standard statutory fire policy and extended coverage, vandalism and malicious mischief endorsements thereon, as
approved by the Commissioner."
If the Essential Property Insurance policy listed below is terminated or cancelled and you are unable to replace the coverage through a
licensed insurer, you may be eligible for Essential Property Insurance through the North Carolina Joint Underwriting Association
(FAIR Plan) or the North Carolina Insurance Underwriting Association (Beach Plan). You should contact your Agent or the
Associations for details.
Owner of Property to be Insured: __________________________________________________________________
Location of Property to be Insured: ________________________________________________________________
_____________________________________________________________________________________________
Name of Insurance Company providing Essential Property Insurance: (If the Essential Property Carrier required completion
of a Form F Application, Windstorm and Hail coverage is not available through the NCIUA.)
_____________________________________________________________________________________________
Company Underwriting Office: ___________________________________________________________________
Telephone Number: (____)___________________ Name of Underwriter: ________________________________
Policy Number: _____________________Inception Date: _____/_____/_____ Expiration Date: _____/_____/_____
(The Windstorm & Hail Policy and the Wrap Around Policy must be as concurrent as possible. Exception: The Association reserves
the right to require a different deductible than the Essential Property Carrier. A Short Term Policy will be written to satisfy the date
concurrency requirement.)
Amount of Essential Property Insurance in Force: Building: $__________________ Personal Property: $________________
Essential Property Policy’s Deductible $______________Commercial Only-Business Income: $ _________________
Residential Wind Driven Rain Coverage Desired? ____Yes ____No (check one) This coverage is not available in Commercial
Property. Residential Wind Driven Rain Coverage is only available if the essential carrier’s policy would not have excluded Wind
Driven Rain, and is applicable to building coverage only. A copy of the essential carrier’s policy is needed for proof of coverage if
that policy is other than HE-7, HO-3 or DP-3.
If Essential Property Policy is written on Commercial Form, show Fire Class Rate CSP Code: ________________
Essential Policy's Applicable Basic Policy Form(s): _________________________________________________
Replacement Cost Provided (check one) ___Yes ___No Building; ___Yes ___No Personal Property
(Note: Replacement Cost on Personal Property is not available over a Dwelling Fire Policy)
Dwelling is (check one): _____ Primary Location _____ Secondary Location
Does this Essential Property Insurance Policy include "Write Your Own" flood coverage? (check one) ____ Yes ____ No
********************************************
I certify that the policy referenced above is in force at this time.
Signature: _____________________________________________ Date: ___________________________
WH0005 09 07

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