Form 81-43 Notice of Loss

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

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

NOTICE OF LOSS

(See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice)

1. NAME OF SERVICING OFFICE

7. POLICY NUMBER
FL

8. POLICY PERIOD (From, To)

2. AGENCY NAME AND MAILING ADDRESS (Rubber stamp or type)

9. DATE OF LOSS

10. KIND OF LOSS

11. PROBABLE AMOUNT OF
LOSS-ALL PERILS
$

Flood
Mudslide
12. ESTIMATE OF LOSS-THIS
POLICY
$

13. OTHER INSURANCE (See Item 18.)
Yes

No

Buildings

Contents

14. REMARKS: BRIEF DESCRIPTION OF DAMAGE (If emergency
handling required, explain why)

3. INSURED

4. PROPERTY

PHONE NO.

5. MAIL ADDRESS

PHONE NO.

6. LOCATION OF PROPERTY IF REMOVED FOR PROTECTION

15. DESCRIPTION OF PROPERTY COVERED
ITEM
NO.

AMOUNT
INSURANCE

DESCRIPTION
16. MORTGAGE (BUILDING)

1
$
Bldg.

On the

Family

Bsmt.Yes

No

Story building of

Construction.

On the contents in the Building described above
2
$
Conts.

or in the

Family

Building of
Bsmt.Yes

17. LOSS PAYEE (CONTENTS)

Story

Construction.
No

18. LIST ANY OTHER INSURANCE APPLICABLE TO THE PROPERTY DESCRIBED IN ITEM 15 ABOVE INCLUDING: HOMEOWNERS, WIND AND/OR EXCESS POLICY;
COVERAGE ON SPECIFICALLY DESCRIBED ARTICLES, E.G., FURS, JEWELRY, ETC. PLEASE PROVIDE POLICY NUMBERS AS APPLICABLE.

19.

CATASTROPHE SERIAL NO.

CAT. ZONE NO.

DATED

COPIES
SENT TO
20. NAME OF ADJUSTER TO WHOM THIS NOTICE HAS BEEN FORWARDED

21. NAME OF ADJUSTER HANDLING E/C OR OTHER INSURANCE LOSS

THIS SPACE FOR USE BY SERVICING OFFICE

The Standard Flood Insurance Policy is subject to the National Flood Insurance Act of 1968, and any Acts Amendatory thereof, and Regulations
issued by the Federal Insurance Administration pursuant to such statute(s).
FEMA Form 81-43, JUL 04

REPLACES ALL PREVIOUS EDITIONS

F-102 (7/04) (6/03)

INSTRUCTIONS FOR AGENTS OR BROKERS:
1. Complete this Notice of Loss in its entirety. DO NOT OMIT ANY INFORMATION.
2. Forward the completed notice to NFIP shown on the Declarations Sheet of the Policy.
3. All losses under Flood Policies will be assigned to adjusters by NFIP.
4. Agents and Brokers are not permitted to adjust losses under Flood Policies.
5. Additional Flood Notices of Loss may be obtained from:
FEMA/MAP Service Center
P.O. Box 1038
Jessup, MD 20794-1038
1-800-358-9616
INSTRUCTIONS FOR ADJUSTERS:
1. Obtain necessary forms for the adjustment of Flood Losses from NFIP assigning the loss.
2. Preliminary reports and estimates must be submitted to NFIP not later than ten working days from the date of assignment.
3. Preliminary reports must indicate the height of the water, to the nearest foot, above or below the first floor level of the risk involved.

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

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

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