Form 81-44 NFIP Statement of Full Cost or Replacement

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

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

Statement as to full cost of repair or replacement
under the replacement cost coverage, subject
to the terms and conditions of this policy*
(See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice)

Policy No. FL ........................................................................
Agency at ...................................................... Agent ..................................................................................
Insured .......................................................................................................................................................
Location ......................................................................................................................................................
Type of property involved in claim ..................................................................................................................
Date of loss .................................................................................................................................................

1. Full Amount of Insurance applicable to the property
for which claim is presented was .............................................................

$

2. Full Replacement Cost of the said property at the time
of the loss was ......................................................................................

$

3. The Full cost of Repair or Replacement is ..................................................

$

4. Applicable Depreciation is ........................................................................

$

5. Actual Cash Value loss is ........................................................................

$

(Line 3 minus Line 4)

6. Less deductibles and/or participation by the insured ...................................

$

7. Actual Cash Value Claim is ....................................................................

$

(Line 5 minus Line 6)

8. Supplemental Claim, to be filled in accordance with the
terms and conditions of the Replacement Cost Coverage
within ..... days from date of loss as shown above,
will not exceed ...................................................................................

$

(This figure will be that portion of the amounts shown on Lines 4 and 6
which is recoverable)

* 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).

......................................................................... Insured

........................................................................ Adjuster

FEMA Form 81-44, JUL 04

REPLACES ALL PREVIOUS EDITIONS

F-103 (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