Form 81-41 NFIP Building Worksheet

O.M.B. No. 1660-0005
Expires JUNE 30, 2007

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM

WORKSHEET - BUILDING
(See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice)
DATE OF REPORT
Policy No. FL

INSURED AND LOCATION
ADJUSTING FIRM AND ADDRESS

Adjuster's File
No.

(ADJUSTER)
TYPE OF BUILDING

Date of Loss

AGE

MEASURE DIMENSIONS AND DRAW DIAGRAM OF GROUND FLOOR
AREA. ATTACH SNAPSHOT
BUILDING DIMENSIONS

TOTAL SQ. FT.

NO. ROOMS

TYPE OF FOUNDATION

FINISHED BASEMENT

NO. STORIES

INTERIOR WALL
CONSTRUCTION

EXTERIOR WALL
CONSTRUCTION

NO

YES

NO. BATHS

Estimated Replacement Cost

Less Depreciation

Actual Cash Value

QUANTITY

FEMA Form 81-41, JUL 04

DETAILED DESCRIPTION

FULL COST
REPAIR

REPLACES ALL PREVIOUS EDITIONS

DEPRECIATION

FLOOD
LOSS

WIND LOSS
(If any)

F-099 (7/04)

Privacy Act Statement
The information requested is necessary to process the subject loss. The authority to collect the information is Title 42, U.S. Code,
Section 4001 to 4028. It is voluntary on your part to furnish the information. However, omission of an item may preclude processing of
the form. The information will not be disclosed outside of the Federal Emergency Management Agency, except to the servicing agent,
acting as the government's fiscal agent; to claims adjusters to enable them to confirm coverage and the location of insured property; to
certain Federal, State, and Local Government agencies for determining eligibility for benefits and for verification of agencies for
acquisition and relocation-related projects, consistent with the National Flood Insurance Program and consistent with the routine uses
described in the program's system of record. Failure by you to provide some or all of the information may result in delay in processing
or denial of this claim and/or application.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for the collection of information titled Claims for National Flood Insurance Program (NFIP) is estimated to
average 4 hours per claim. This estimate includes the time, effort, or financial resources expended by persons to generate, maintain,
retain, disclose, or provide information to the Mitigation Division or its agent. The reporting burden for this form as part of the
collection of information is highlighted below. You are not required to respond to this collection of information unless a currently valid
OMB control number and expiration date is displayed in the upper right corner of the highlighted form. You may send comments
regarding the accuracy of the burden estimate and suggestions for reducing the burden to: Information Collections Management, U.S.
Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, S.W., Washington, DC 20472, Paperwork
Reduction Project (1660-0005). NOTE: Do not send your completed form to this address.
FEMA Form No.
81-40
81-41
81-41A
81-42
81-42A
81-43
81-44

81-57
81-58
81-59
81-63
81-96
81-98

Title
Worksheet-Contents-Personal Property
Worksheet-Building
Worksheet-Building (Cont'd)
Proof of Loss
Increased Cost of Compliance
Notice of Loss
Statement as to Full Cost to Repair or Replacement
Cost Coverage, Subject to the Terms and Conditions
of this Policy
National Flood Insurance Program Preliminary Report
National Flood Insurance Program Final Report
National Flood Insurance Program Narrative Report
Cause of Loss and Subrogation Report
Mobile Home Worksheet
Increased Cost of Compliance (ICC) Adjuster Report

Burden Hours
2.5 Hours
2.5 Hours
1.0 Hours
5 Minutes
2.0 Hours
4 Minutes
6 Minutes

4 Minutes
4 Minutes
5 Minutes
1 Hour
30 Minutes
25 Minutes