Form 81-63 Cause of Loss and Subrogation Report

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

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

CAUSE OF LOSS AND SUBROGATION REPORT
NAME OF INSURED

O.M.B. No. 1660-0005
Expire JUNE 30, 2007
POLICY NO.

COMPLETE ADDRESS OF PROPERTY DAMAGED

CAUSE OF LOSS (Check the box(es) that apply)
1.

IMPROPER DIVERSION OF WATER

7.

NEGLIGENT MAINTENANCE OF SEWER LINES

2.

IMPROPER BUILDING

8.

FAILURE TO USE PUMPS

3.

IMPROPER GRADING

9.

INADEQUATE PUMPS

4.

DEBRIS ACCUMULATION

10.

EXCESSIVE DAM WATER RELEASE

5.

INADEQUATE SEWER LINES

11.

EXCESSIVE WATER RELEASE (Mechanical)

6.

IGNORING FLODDPLAIN MANAGEMENT (Regulations)

12.

ANY OTHER FACTOR THAT IDENTIFIES A RESPONSIBLE
PARTY OR ACT AS THE CAUSE (Explain; use the space below)

IDENTIFICATION OF RESPONSIBLE PARTY
NAME
COMPLETE ADDRESS

IS THE RESPONSIBLE PARTY INSURED?
NO (If yes, by whom?)
YES
IDENTIFICATION OF ANY STATUTES OR POLITICAL SUBDIVISION THAT WOULD CONTROL, LIMIT, OR TIME BAR A TORT ACTION AGAINST
THEM (e.g., a local notice of claim against the municipality or county statute that would preclude suit if the notice was not filed on time - usually a
short period of time for filing is provided).

MAKE IMMEDIATE TELEPHONE CONTACT WITH THE NFIP BUREAU AND STATISTICAL AGENT IF EXPIRATION OF TIME IS IMMINENT.
STATE INVESTIGATION PERFORMED TO DATE

PLEASE ATTACH ANY DEFINITIVE MATERIAL TO THIS REPORT.
WHAT FURTHER INVESTIGATION IS CONTEMPLATED?

HAS INSURED BEEN ADVISED OF SUBROGATION POSSIBILITIES?
NO (If yes, by when?)
YES
DOES INSURED HAVE AN ATTORNEY?
NO
YES
FEMA Form 81-63, JUL 04

NAME OF ATTORNEY
REPLACES ALL PREVIOUS EDITIONS

F-092 (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