Form 81-96 Mobile Home Worksheet

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

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

Manufactured (Mobile)
Home/Travel Trailer Worksheet
POLICY NO.:

DATE OF LOSS:

INSURED:

TYPE OF FOUNDATION:

LOCATION OF RISK:

MANUFACTURER

MODEL

YEAR

SIZE

SERIAL NUMBER

COLOR

NO. OF BEDROOMS

TYPE OF TIE DOWN

DATE OF PURCHASE

COST

NEW OR USED

WAS FURNITURE INCLUDED?

AMOUNT

SALVAGE VALUE

SALVOR

BOOK USED

ADDITIONS OPTION

AVERAGE DEALER APPRAISAL

REPAIRABLE

YES

NO

Repair figures agreed with repairman

BOOK VALUE

DEALER APPRAISAL
DEALER & LOCATION

DID DEALER VIEW UNIT?
VALUE

REPLACEMENT
AVAILABLE

MAKE OF REPLACEMENT
IF DIFFERENT

Draw in location and dimensions of rooms. Also, indicate location of tie downs and any additions.
Number of Axles

Are Wheels on Unit?
Remarks:

OTHER INSURANCE CO.

Adjuster:

POLICY NO.

AMOUNT OF INSURANCE
BC-

COVERS FLOOD
YES
NO

TYPE OF POLICY

Remarks:

This worksheet must be completed on all manufactured (mobile) home/travel trailer losses. Copies may be obtained by calling
1-800-480-2520 or writing to the FEMA Distribution Center, P.O. Box 2012, Jessup, MD 20794-2012.
FEMA Form 81-96, JUL 04

REPLACES ALL PREVIOUS EDITIONS

F-136 (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