Form 81-110 Adjuster Certification Application

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

NATIONAL FLOOD
INSURANCE PROGRAM

ADJUSTER CERTIFICATION APPLICATION

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.

Recertification
New Certification
Staff Adjuster
Yes
No
Please complete Section I below in its entirety. Then turn the form over and complete all applicable parts of Section II. Sign and
date the form and mail it to: NFIP Bureau & Statistical Agent, Certification Coordinator, P.O. Box 310, Lanham, MD 20703-0310
SECTION I - PLEASE PRINT
1. NAME

2. FLOOD CERTIFICATION NUMBER (FSN)

3. STREET ADDRESS (Include City, State, and Zip code

a. DAYTIME PHONE NO.
b. EVENING PHONE NO.
c. E-MAIL ADDRESS
d. FAX NO.

4. Are you a licensed adjuster?

Yes

No

If yes, which state(s)?

5. Number of years of flood adjuster experience

Number of years of property adjuster experience

6. Has your license ever been revoked?

Yes

No

Yes

No

Yes

No

Yes

No

If yes, reason:
7. Have you ever been suspended or terminated by the NFIP?
If yes, reason:
8. Have you ever attended an NFIP Claims Presentation?
If yes, location:
9. Did you attend a company sponsored training session?
If yes, location:

Date Attended:
Company:

Date Attended:

10. Present Errors and Omissions Carrier:
SECTION II - PLEASE PRINT
Check "Yes" or "No" to indicate the category(s) in which you are seeking certification:
11. Residential (Dwelling)

Yes

No

12. Manufactured (Mobile) Home/Travel Trailer

Yes

No

13. Small Commercial (up to $100,000)

Yes

No

14. Large Commercial (from $100,001 to $500,000)

Yes

No

15. Condominium (RCBAP)

Yes

No

Commercial (General Property)

FEMA Form 81-110, JUL 04

F-673 (7/04)

SECTION II - (Cont.)
For the category(ies) that you have selected, answer the following questions:
* What is the building dollar limit estimate that you have prepared in this category?

* What is the dollar limit on contents inventory that you have prepared?

* What is the largest combined loss and claim that you have adjusted?
Building $

Contents $

Total Amount $

If you have adjusted a condominium loss, provide the name, date of loss, location (complete address), and contact individual, along with telephone
number.

If you are applying for Large Commercial or RCABAP authorization, provide the names of three insurance company claims personnel who can be
contacted to reference you adjusting experience and professionalism.
NAME

COMPANY

DATE

NAME

COMPANY

DATE

NAME

COMPANY

DATE

DECLARATION ACKNOWLEDGMENT
I declare that I have read the current Standard Flood Insurance Policies (the Dwelling Form, the General Property Form, and the Residential
Condominium Building Association Policy) and that all responses on this application are true and accurate.
I acknowledge that mispresentation of any information provided on this application is ground for denial of certification, or for suspension or
termination of certification if mispresentation is discovered after certification has been granted.

Signature

Date