Form 81-109 Adjuster Preliminary Damage Assessment

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

ADJUSTER PRELIMINARY DAMAGE ASSESSMENT

NATIONAL FLOOD
INSURANCE PROGRAM

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

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 nonduplication of
benefits; to the Department of Justice for purposes of litigation or as required by law; and to State and Local 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 this form is estimated to average 15 minutes per response. The burden 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. 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. Send
completed forms to: NFIP Bureau & Statistical Agent, Certification Coordinator, P.O. Box 310, Lanham, MD 20703-0310.
WYO COMPANY

DATE OF LOSS

ADJUSTER

FICO NUMBER

This form is to be used for advisory purposes in helping FEMA and communities identify potential substantially damaged buildings. The adjuster
will use"replacement cost" when completing this form; however, the community is required under the National Flood Insurance Program to use
"market value" in determining substantial damage.
PLEASE PRINT LEGIBLY
POLICY HOLDER

POLICY NUMBER

PROPERTY ADDRESS (include zip code)

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE

BUILDING ACTUAL CASH VALUE

$

$

POLICY HOLDER

POLICY NUMBER

PROPERTY ADDRESS (include zip code)

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE

BUILDING ACTUAL CASH VALUE

$

$

POLICY HOLDER

POLICY NUMBER

PROPERTY ADDRESS (include zip code)

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE

BUILDING ACTUAL CASH VALUE

$

$

**This is an estimate of the cost to repair the building to its pre-flood condition.
FEMA Form 81-109, JUL 04

F-674 (7/04)