Form 81-58 NFIP Final 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.

FINAL REPORT
INSURED

POLICY NUMBER

PROPERTY ADDRESS

DATE OF LOSS

ADJUSTING COMPANY

ADJ. FILE NO.

Date risk was originally constructed:

PREMISES HISTORY

Date of Alteration

Insured at premises since:

Brief Description of Alteration

Market Value

Cost of Alteration

Type of Alteration

*Substantial Improvement?

Repair

Recon.

Imprv.

Yes

No

Repair

Recon.

Imprv.

Yes

No

Repair

Recon.

Imprv.

Yes

No

*Defined as any repair, reconstruction, or improvement; the cost of which equals or exceeds 50% of the market value of the structure before the damage occurred
or the reconstruction or improvement was begun.
Prior losses (approximate dates and amounts of loss):
Repairs completed?

Yes

No

Insured?

Yes

No

Insured but no claim made

Repairs completed?

Yes

No

Insured?

Yes

No

Insured but no claim made

Repairs completed?

Yes

No

Insured?

Yes

No

Insured but no claim made

INTEREST

(Continue under Remarks if additional space is needed for alteration or prior losses.)
Mortgagee(s):
Loss Payee(s):
Other Insurance:

Yes
(Company)

Duration building will not be habitable: 1 0-2 days

(Type)

(Policy Number)

2 3-7 days

3 2-4 weeks

(Coverage Bldg./Conts.)
4 1-2 months

No

(Covers flood?)

5 more than 2 months

Claim Recapitulation (See worksheets for details)
Contents

Building
Main*/Association

Appurtenant/Unit

Totals

Appurtenant/Unit

Main*/Association

Property Value (RCV)
CLAIM SUMMARY

Property Value (ACV)
Gross Loss (RCV)
Covered Damage (ACV)
Removal/Protection
Total Loss (ACV)
Less Salvage
Less Deductible
Excess Over Limit
Claim Payable (ACV)
Damage from other
Identify Cause:
Main building RCV: $
*Includes mobile home.

Excluded
Building
Damages:

1
2
3

Less than 1,000

Excluded
Contents
Damages:

1
2
3

Less than 1,000

Building worksheets

1,000 - 2,000
2,000 - 5,000
1,000 - 2,000
2,000 - 5,000

(

)

Photographs (

Contents worksheets: (

)

Narrative (

5,000 - 10,000
4
5 10,000 - 20,000
6 More than 20,000

1
2
3

Less than 1,000

5,000 - 10,000
4
5 10,000 - 20,000
6 More than 20,000

1
2
3

Less than 1,000

)
pp)

1,000 - 2,000
2,000 - 5,000
1,000 - 2,000
2,000 - 5,000

5,000 - 10,000
4
5 10,000 - 20,000
6 More than 20,000
5,000 - 10,000
4
5 10,000 - 20,000
6 More than 20,000

Other

Proof of Loss
R/C Proof

Not Applicable

Approximate damage to property excluded:

Approximate value of property excluded:

EXCLUDED DAMAGES
ENCL
CERTIFICATION

No
Yes
Total building claim: $

Insured qualifies for R/C coverage
If yes, R/C claim: $

Other

The above statements are true and correct to the best of my knowledge. I understand that any false statements may be punishable by fine or imprisonment under
18 U.S. Code Sec. 1001.
County of

Insured

State of

Insured

Signed this

day of

Date of Report

FEMA Form 81-58, JUL 04

, 20

Witness

Adjuster's Signature

REPLACES ALL PREVIOUS EDITIONS

Adjuster's SSN

F-094 (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 Federal Insurance Administration or its agent. The reporting burden for this form as part
of the collection of information is highlighted below. Your response 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, Emergency Preparedness and Response Directorate, 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