Form 81-57 NFIP Preliminary Report

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

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

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

THE NFIP REQUIRES THAT A PRELIMINARY REPORT BE RECEIVED WITHIN 15 DAYS OF ASSIGNMENT,
AND AN INTERIM OR FINAL REPORT NOT LATER THAN EVERY 30 DAYS THEREAFTER.

PRELIMINARY REPORT
INSURED

POLICY NUMBER

PROPERTY ADDRESS

DATE OF LOSS

MAILING ADDRESS

CATASTROPHE NO.

INSURED TELEPHONE NUMBER: HOME

WORK

ADJ. FILE NO.

ADJUSTING COMPANY

TAX ID NUMBER

ADJUSTER ADDRESS

ADJ. PHONE NO.

DATE LOSS ASSIGNED

DATE INSURED CONTACTED

ENCL.

Building worksheets

(

)

Contents worksheets (

)

Photographs (
Narrative

INSURANCE

Coverage verified from:
Term

NFIP

)

(

Other

Proof of Loss

pp)

R/C Proof

Agent's Daily

Other

Insured's Policy

to

Program:

Dwelling
Deductible
$
RESERVES: Building
Contents
$
ADVANCE PAYMENT REQUESTED?
No
Yes: Building $
Contents $
If yes, Proof of Loss for amount of payment and supporting documentation must be submitted with this report.
Type of Building:

Form:
Coverage
$
$

2-4 Family

Single Family

Mobile Home/Travel Trailer:

Condo Association

Condo Unit

Make:

Model:

Occupancy:

Owner

Tenant

State government owned

Title verified?

Yes

No

Source of verification:

Number of floors in building including basement:

1

2

In case of multiple occupancy, indicate floor(s) occupied by insured:
Type of basement:
Building elevated?

RISK

DATE LOSS INSPECTED

No

Is risk under construction?

Yes

Foundation area enclosure?

No

New building

Residency:

13 Steel

Exterior wall structure: 1 Reinf. concrete
4 Steel and glass

5 Brick or stone

Contents are:

Piers:

41 Reinf. concrete

Finished
None

22 Reinf. block

42 Block

43 Reinf. concrete shear

6 Other

Household

Other than household

No

Poor

Yes
Unfinished

No
Finished

Fair

Good

Very Good

Fair

Good

Very Good

23 Unreinf. block

24 Brick

25 Other

44 Treated plywood

45 Brick

46 Other

2 Stone/brick veneer
Exterior wall surface treatment: 1 Unfinished
3 Stucco
4 Wood siding
5 Metal sheathing/siding
6 Vinyl sheathing/siding

Contents located in:

Basement and first floor
Nearest body of water:

7 Other

Basement

First floor

First floor and above

Second floor and above

Distance from risk:

Was there a general and temporary condition of flooding:

No: Explain fully under remarks

Yes: Indicate cause of loss

Cause of loss:

1 Tidal water overflow

2 Stream, river, or lake overflow

3 Alluvial fan overflow

Flood characteristics:

1 Velocity flow

2 Low velocity flow or ponding

3 Wave action

4 Accumulation of rainfall or snowmelt

4 Mudflow

Was flood associated with failure of a dam, storm drain, storm drain system, pump(s), other flood control measure, etc?
ORIGIN

Yes

Breakaway walls

21 Reinf. concrete

3 Wood stud

Seasonal

Is basement floodproofed?

Improvement in progress Prior condition of:
Building:
Poor

2 Concrete block

Principal

Second and/or above

Contents:
Foundation Structure:
11 Concrete 12 Wood
Piles:
30 Wood posts
Walls:
50 Concrete slab
60 Other

Non-Residential

Is building a split level?

First

Unfinished

RCBAP

Serial Number:

3 or more

None

Regular

General Property
Reserve
$
$

Other Residential

Unoccupied

Basement

Emergency

Did other than natural cause contribute to flooding?
Date/time water entered building

Yes

No

5 Erosion

Yes

No

If "yes" to either question, complete "Cause of Loss and Subrogation Report"

Water Height or Wave Action:

Exterior

Interior

Date/time water receded building
Length of time water remained in building

Date of Report

FEMA Form 81-57, JUL 04

Main Building/Condo Assn.:
Apt. Building/condo Unit:

Adjuster's Signature

REPLACES ALL PREVIOUS EDITIONS

Adjuster's SSN

F-093 (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