Form 81-42A Increase Of Compliance Proof of Loss

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

INCREASED COST OF COMPLIANCE PROOF OF LOSS

NATIONAL FLOOD
INSURANCE PROGRAM

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

POLICY NUMBER

POLICY TERM

AMOUNT OF BLDG. AT TIME OF LOSS

AGENT

AGENCY AT

DATE OF LOSS

TO THE NATIONAL FLOOD INSURANCE PROGRAM:
At the time of loss, by the above indicated policy of insurance, you insured the interest of
against loss by flood to the building property described according to the terms and conditions of said policy and of all forms,
endorsements, transfers, and assignments and attachments thereto.
TIME AND ORIGIN:

An increased cost of compliance claim was filed on
option selected was

. The mitigation

OCCUPANCY:

The described building was occupied at the time of the flood loss as follows, and for no other purpose
whatever as:

INTEREST:

No other person or persons had any interest therein or encumbrance thereon except

1. FULL AMOUNT OF ICC INSURANCE application to the property for which claim is presented is
2. REPLACEMENT COST VALUE of building structure
3. ACTUAL CASH VALUE of building structure
4. FULL COST OF COMPLIANCE not limited to the amount of ICC coverage
5. AMOUNT PAID under Coverage A
6. AMOUNT PAID under the ICC Coverage D (excluding salvage and subrogation)
The said loss did not originate by any act, design or procurement on the part of your insured, nothing has been done by or
with the privity or consent of your insured to violate the conditions of the policy, or render it void; no articles are mentioned
herein or in annexed schedules but such as were destroyed or damaged at the time of said loss, no property saved has in any
manner been concealed, and no attempt to deceive the said insurer as to the extent of said loss, has in any manner been made.
Any other information that may be required will be furnished and considered a part of this proof.
I understand that this insurance (policy) is issued Pursuant to the National Flood Insurance Act of 1968, or Any Act Amendatory
thereof, and Applicable Federal Regulations in Title 44 of the Code of Federal Regulations, Subchapter B, and that knowingly and
willfully making any false answers or misrepresentations of fact may be punishable by fine or imprisonment under applicable
United States Codes.
Subrogation - To the extent of the payment made or advanced under this policy; the insured hereby assigns, transfers and
sets over to the insurer all rights, claims or interest that he has against any person, firm or corporation liable for the loss or
damage to the property for which payment is made or advanced. He also hereby authorizes the insurer to sue any such third
party in his name.
The insured hereby warrants that no release has been given or will be given or settlement or compromise made or agreed
upon with any third party who may be liable in damages to insured with respect to the claim being made herein.
The furnishing of this blank or the preparation of proofs by a representative of the above insurer is not a waiver of any of its
rights.
State of
County of
Subscribed and sworn before me this

day of

20

Notary Public

FEMA Form 81-42A, JUL 04

REPLACES ALL PREVIOUS EDITIONS.

F-554 (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
Department of Homeland Security, Emergency Preparedness and Response Directorate, 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
FEMA FORM 81-42A
Public reporting burden for this form is estimated to average 2 hours per response. The burden estimate includes
the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data,
and completing and reviewing the form. You are not required to respond to this collection of information unless a
valid OMB control number is displayed in the upper right hand corner of this form. Send comments regarding the
accuracy of the burden estimate and any 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.