Form 81-98 Increased Cost of Compliance Adjuster Report

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

NATIONAL FLOOD
INSURANCE PROGRAM

INCREASED COST OF COMPLIANCE (ICC)
ADJUSTER REPORT

O.M.B. No. 1660-0005
Expire JUNE 30, 2007
Privacy Act Statement on
reverse

2. NAME OF INSURER

1. NAME OF INSURED

3. PROPERTY ADDRESS (Inlcude city, state, and zip code)

4. COMMUNITY NAME/NUMBER

5. FLOOD ZONE

6. POLICY NUMBER

7. POLICY TERM

8. BUILDING POLICY LIMIT

9. DATE OF LOSS

10. OCCUPANCY TYPE
11. ADJUSTING COMPANY

12. ADJUSTER FILE NO.

13. Has the Insured received a determination from the community official that the structure must be brought into compliance with the
no
local floodplain management ordinances?
yes
14. Local Official's Name:

Telephone Number:

15. Under the flood loss meet the NFIP/ICC 50% substantial damage or average 25% repetitive loss requirements?
no
yes
16. Under which provision is the ICC claim based?
Mitigation option(s):

Substantial Damage

Demolition
Elevation
Demolition/Elevation or Floodproofing

Repetitive Loss
Floodproofing
Relocation
Relocation/Elevation or Floodproofing

17. If relocation, indicate the following:
New address:

New flood risk zone:

18. Current valuation of structure as determined by the community official $
19. Basis of valuation:
20. Full cost of compliance not limited to the amount of ICC coverage

$

21. Amount paid under the ICC Coverage D (excluding salvage and subrogation)

$

If repetitive loss, indicate the following (paid flood building claims only):
Date of Prior Claim Insurer
within 10 yrs.

Policy Number

Building Payment

RCV Damages
(whole dollars)

ACV Damages
(whole dollars)

22. If repetitive loss, the valuation of the structure as determined by the community official near the date of the prior loss:
Date of valuation:
$
23. Basis of valuation:
24. DATE OF REPORT

FEMA Form 81-98, JUL 04

25. ADJUSTER'S SIGNATURE

REPLACES ALL PREVIOUS EDITIONS

26. ADJUSTER'S SSN

F-555 (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
FEMA Form 81-98
Public reporting burden for this form is estimated to average .25 hours per response. The burden estimate
includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the
needed data, and completing and reviewing the form. You are not required to respond to this collection of
information unless a valid OMB control number is displayed in the upper right hand corner of this form. Send
comments regarding the accuracy of the burden estimate and any 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.