Form FEMA Form 086-0-1 FEMA Form 086-0-1 Flood Insurance Application

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Program
part 1 (of 2) of flood insurance application

Renewal

important—please print or type

policy
term

DIRECT BILL INSTRUCTIONS:
BILL INSURED
BILL SECOND
MORTGAGEE
BILL OTHER

POLICY PERIOD IS FROM
TO
12:01 A.M LOCAL TIME AT THE INSURED PROPERTY LOCATION
Waiting period:
 standard 30-day
map rev. (zone change from non-sfHa to sfHa)—one Day
loan—no waiting
Lender Required—No Waiting

BILL FIRST MORTGAGEE
BILL LOSS PAYEE

name, mailing Address, and telephone no. of insured:

insured
mail address

agent’s tax id:
fax no.:

is insurance required for disaster assistance?
If yes, check the government agency:
sba
other (specify):
enter case file number

yes
fema

no
fha

property
location

disaster
assistance

agent
information

Name, Address of licensed property or casualty insurance agent or broker:

agency no.:
phone no.:

community

2nd mortgageE/
Other

mortgageE

name and Address of first mortgagee

loan no.:
phone no.:

fax no.:

Rating map information
NAME OF COUNTY/PARISH
COMMUNITY No./PANEL No. AND SUFFIX
FIRM zone
COMMUNITY PROGRAm TYPE IS:
REGULAR

EMERGENCY

building
contents
construction data

yes

no

2

3 or more

split level

BASEMENT, ENCLOSure, crawlspace
NONE
manufactured (mobile)
FINISHED basement/enclosure
home/travel trailer on
UNFINISHED basement/enclosure
foundation
crawlspace
IF NOT A SINGLE FAMILY DWELLING,
subgrade crawlspace
THE NUMBER OF OCCUPANCIES
(UNITS) IS

yes

no
BUILDING USE
Main house/building
Detached guest house
Detached garage
Agricultural building
Warehouse
Poolhouse, clubhouse,
recreation building
tool/storage shed

IS BUILDING walled and roofed?
yes
no
IS BUILDING over water?
no
partially
entirely

IS BUILDING INSURED’S PRINCIPAL
RESIDENCE?
yes
no

N
F
I
P

Other:

IS BUILDING elevated?
yes
no
If yes, area below is:
free of obstruction
with obstruction
if elevated, complete part 2
of application

ESTIMATED REPLACEMENT COST
amount $

FOR MANUFACTURED (MOBILE)
HOMEs/travel trailers,
complete part 2, section III.

C
O
P
Y

lowest floor above ground level and higher
above ground level more than one full floor
(if single family, contents are rated throughout the building)
yes

no

If no, please describe:

ALL BUILDINGS: (CHECK ONE OF THE FIVE BLOCKS and record corresponding date in the date box)
BUILDING PERMIT DATE
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED IN A MOBILE HOME PARK
OR SUBDIVISION: CONSTRUCTION DATE OF MOBILE HOME PARK OR SUBDIVISION
DATE OF CONSTRUCTION
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED OUTSIDE A MOBILE HOME PARK OR
SUBSTANTIAL IMPROVEMENT DATE
SUBDIVISION: DATE OF PERMANENT PLACEMENT

DATE:
_______/_______/_______
(MM/DD/YYYY)

yes
no
IS BUILDING POST-FIRM CONSTRUCTION?
IF POST-FIRM CONSTRUCTION IN ZONES A, A1-A30, AE, AO, AH, V, V1-V30, VE, OR IF PRE-FIRM CONSTRUCTION IS ELEVATION RATED, attach certification.
Building Diagram Number
lowest adjacent grade (LAG)
Elevation certificate date
LOWEST FLOOR ELEVATION
(–) BASE FLOOD ELEVATION
(=) DIFFERENCE TO NEAREST FOOT
(+ OR –)
IN ZONES V AND V1-V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?
yes
no
IS BUILDING FLOOD-PROOFED?
(SEE FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)
BUILDING $

CONTENTS $

coverage

amount of
insurance

rate

Deductible buyback?

additional limits
(regular program only)

basic limits
coverage and rating

fax no.:

IS THIS BUILDING IN THE COURSE OF
yes
no
CONSTRUCTION?

Residential Condominium
Building Association policy
only: Total number of units
(include non-res.)
high-rise
low-rise

townhouse/rowhouse
(rcbap lowrise only)

DEDUCTIBLE:

signature

loan no.:
phone no.:

condo form of ownership?
yes
no
Condo coverage is for:
unit
entire building

1

is personal property household contents?

IF SECOND MORTGAGEE, LOSS PAYEE OR OTHER IS TO BE BILLED, COMPLETE
the following, INCLUDING THE NAME AND ADDRESS.
2ND MORTGAGEE
DISASTER AGENCY
LOSS PAYEE
IF OTHER, PLEASE SPECIFY:

IS BUILDING located on federal land?

Number of floors in entire
building (include basement/
enclosed area, if any) or
building type

contents located in:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level

IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. IF RURAL,
DESCRIBE PROPERTY LOCATION (DO NOT USE P.O. BOX).

Grandfathered?
yes
no
If yes,
Built in compliance?
Continuous coverage? Prior policy no.
Current COMMUNITY No./PANEL No. AND SUFFIX
—
Current FIRM zone
Current BFE

—

IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
BUILDING OCCUPANCY
SINGLE FAMILY
2-4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)

current policy number

New

annual
premium

amount of
insurance

rate

annual
premium

yes

yes

no

no

deductible

basic and
additional

prem. reduction/ increase

total amount
of insurance

total
premium

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

Rate type: (one building per policy—blanket coverage not permitted)
manual
submit for rating
alternative
v-zone risk Factor rating form
provisional rating
leased federal property
mortgage portfolio protection program

payment option:
credit card
other:

FEMA Form 086-0-1, AUG 09

$

icc premium
SUBTOTAL
%

CRS PREMIUM DISCOUNT

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY
FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE federal LAW.
see reverse side of copies 2, 3, & 4.

SIGNATURE OF INSURANCE AGENT/BROKER

ANNUAL SUBTOTAL

DATE (MM/DD/YYYY)

SUBTOTAL
probation surcharge

+

FEDERAL POLICY FEE

+

TOTAL PREPAID AMOUNt

Previously FEMA Form 81-16

PLEASE ATTACH TO NFIP COPY OF APPLICATION THE CHECK OR MONEY ORDER FOR
THE TOTAL PREPAID PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP — IMPORTANT

$

F-050 (8/09)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Program
part 1 (of 2) of flood insurance application

Renewal

important—please print or type

policy
term

DIRECT BILL INSTRUCTIONS:
BILL INSURED
BILL SECOND
MORTGAGEE
BILL OTHER

POLICY PERIOD IS FROM
TO
12:01 A.M LOCAL TIME AT THE INSURED PROPERTY LOCATION
Waiting period:
 standard 30-day
map rev. (zone change from non-sfHa to sfHa)—one Day
loan—no waiting
Lender Required—No Waiting

BILL FIRST MORTGAGEE
BILL LOSS PAYEE

name, mailing Address, and telephone no. of insured:

insured
mail address

agent’s tax id:
fax no.:

is insurance required for disaster assistance?
If yes, check the government agency:
sba
other (specify):
enter case file number

yes
fema

no
fha

property
location

disaster
assistance

agent
information

Name, Address of licensed property or casualty insurance agent or broker:

agency no.:
phone no.:

community

2nd mortgageE/
Other

mortgageE

name and Address of first mortgagee

loan no.:
phone no.:

fax no.:

Rating map information
NAME OF COUNTY/PARISH
COMMUNITY No./PANEL No. AND SUFFIX
FIRM zone
COMMUNITY PROGRAm TYPE IS:
REGULAR

EMERGENCY

building
contents
construction data

yes

no

2

3 or more

split level

BASEMENT, ENCLOSure, crawlspace
NONE
manufactured (mobile)
FINISHED basement/enclosure
home/travel trailer on
UNFINISHED basement/enclosure
foundation
crawlspace
IF NOT A SINGLE FAMILY DWELLING,
subgrade crawlspace
THE NUMBER OF OCCUPANCIES
(UNITS) IS

yes

no
BUILDING USE
Main house/building
Detached guest house
Detached garage
Agricultural building
Warehouse
Poolhouse, clubhouse,
recreation building
tool/storage shed

IS BUILDING walled and roofed?
yes
no
IS BUILDING over water?
no
partially
entirely

IS BUILDING INSURED’S PRINCIPAL
RESIDENCE?
yes
no

A
G
E
N
T

Other:

IS BUILDING elevated?
yes
no
If yes, area below is:
free of obstruction
with obstruction
if elevated, complete part 2
of application

ESTIMATED REPLACEMENT COST
amount $

FOR MANUFACTURED (MOBILE)
HOMEs/travel trailers,
complete part 2, section III.

C
O
P
Y

lowest floor above ground level and higher
above ground level more than one full floor
(if single family, contents are rated throughout the building)
yes

no

If no, please describe:

ALL BUILDINGS: (CHECK ONE OF THE FIVE BLOCKS and record corresponding date in the date box)
BUILDING PERMIT DATE
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED IN A MOBILE HOME PARK
OR SUBDIVISION: CONSTRUCTION DATE OF MOBILE HOME PARK OR SUBDIVISION
DATE OF CONSTRUCTION
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED OUTSIDE A MOBILE HOME PARK OR
SUBSTANTIAL IMPROVEMENT DATE
SUBDIVISION: DATE OF PERMANENT PLACEMENT

DATE:
_______/_______/_______
(MM/DD/YYYY)

yes
no
IS BUILDING POST-FIRM CONSTRUCTION?
IF POST-FIRM CONSTRUCTION IN ZONES A, A1-A30, AE, AO, AH, V, V1-V30, VE, OR IF PRE-FIRM CONSTRUCTION IS ELEVATION RATED, attach certification.
Building Diagram Number
lowest adjacent grade (LAG)
Elevation certificate date
LOWEST FLOOR ELEVATION
(–) BASE FLOOD ELEVATION
(=) DIFFERENCE TO NEAREST FOOT
(+ OR –)
IN ZONES V AND V1-V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?
yes
no
IS BUILDING FLOOD-PROOFED?
(SEE FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)
BUILDING $

CONTENTS $

coverage

amount of
insurance

rate

Deductible buyback?

additional limits
(regular program only)

basic limits
coverage and rating

fax no.:

IS THIS BUILDING IN THE COURSE OF
yes
no
CONSTRUCTION?

Residential Condominium
Building Association policy
only: Total number of units
(include non-res.)
high-rise
low-rise

townhouse/rowhouse
(rcbap lowrise only)

DEDUCTIBLE:

signature

loan no.:
phone no.:

condo form of ownership?
yes
no
Condo coverage is for:
unit
entire building

1

is personal property household contents?

IF SECOND MORTGAGEE, LOSS PAYEE OR OTHER IS TO BE BILLED, COMPLETE
the following, INCLUDING THE NAME AND ADDRESS.
2ND MORTGAGEE
DISASTER AGENCY
LOSS PAYEE
IF OTHER, PLEASE SPECIFY:

IS BUILDING located on federal land?

Number of floors in entire
building (include basement/
enclosed area, if any) or
building type

contents located in:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level

IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. IF RURAL,
DESCRIBE PROPERTY LOCATION (DO NOT USE P.O. BOX).

Grandfathered?
yes
no
If yes,
Built in compliance?
Continuous coverage? Prior policy no.
Current COMMUNITY No./PANEL No. AND SUFFIX
—
Current FIRM zone
Current BFE

—

IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
BUILDING OCCUPANCY
SINGLE FAMILY
2-4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)

current policy number

New

annual
premium

amount of
insurance

rate

annual
premium

yes

yes

no

no

deductible

basic and
additional

prem. reduction/ increase

total amount
of insurance

total
premium

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

Rate type: (one building per policy—blanket coverage not permitted)
manual
submit for rating
alternative
v-zone risk Factor rating form
provisional rating
leased federal property
mortgage portfolio protection program

payment option:
credit card
other:

FEMA Form 086-0-1, AUG 09

$

icc premium
SUBTOTAL
%

CRS PREMIUM DISCOUNT

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY
FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE federal LAW.
see reverse side of copies 2, 3, & 4.

SIGNATURE OF INSURANCE AGENT/BROKER

ANNUAL SUBTOTAL

DATE (MM/DD/YYYY)

SUBTOTAL
probation surcharge

+

FEDERAL POLICY FEE

+

TOTAL PREPAID AMOUNt

Previously FEMA Form 81-16

PLEASE ATTACH TO NFIP COPY OF APPLICATION THE CHECK OR MONEY ORDER FOR
THE TOTAL PREPAID PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP — IMPORTANT

$

F-050 (8/09)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Program
part 1 (of 2) of flood insurance application

Renewal

important—please print or type

policy
term

DIRECT BILL INSTRUCTIONS:
BILL INSURED
BILL SECOND
MORTGAGEE
BILL OTHER

POLICY PERIOD IS FROM
TO
12:01 A.M LOCAL TIME AT THE INSURED PROPERTY LOCATION
Waiting period:
 standard 30-day
map rev. (zone change from non-sfHa to sfHa)—one Day
loan—no waiting
Lender Required—No Waiting

BILL FIRST MORTGAGEE
BILL LOSS PAYEE

name, mailing Address, and telephone no. of insured:

insured
mail address

agent’s tax id:
fax no.:

is insurance required for disaster assistance?
If yes, check the government agency:
sba
other (specify):
enter case file number

yes
fema

no
fha

property
location

disaster
assistance

agent
information

Name, Address of licensed property or casualty insurance agent or broker:

agency no.:
phone no.:

community

2nd mortgageE/
Other

mortgageE

name and Address of first mortgagee

loan no.:
phone no.:

fax no.:

Rating map information
NAME OF COUNTY/PARISH
COMMUNITY No./PANEL No. AND SUFFIX
FIRM zone
COMMUNITY PROGRAm TYPE IS:
REGULAR

EMERGENCY

building
contents
construction data

yes

no

2

3 or more

split level

BASEMENT, ENCLOSure, crawlspace
NONE
manufactured (mobile)
FINISHED basement/enclosure
home/travel trailer on
UNFINISHED basement/enclosure
foundation
crawlspace
IF NOT A SINGLE FAMILY DWELLING,
subgrade crawlspace
THE NUMBER OF OCCUPANCIES
(UNITS) IS

yes

no

IS BUILDING over water?
no
partially
entirely

Other:

IS BUILDING elevated?
yes
no
If yes, area below is:
free of obstruction
with obstruction
if elevated, complete part 2
of application

IS BUILDING INSURED’S PRINCIPAL
RESIDENCE?
yes
no

I
N
S
U
R
E
D

BUILDING USE
Main house/building
Detached guest house
Detached garage
Agricultural building
Warehouse
Poolhouse, clubhouse,
recreation building
tool/storage shed

IS BUILDING walled and roofed?
yes
no

ESTIMATED REPLACEMENT COST
amount $

FOR MANUFACTURED (MOBILE)
HOMEs/travel trailers,
complete part 2, section III.

C
O
P
Y

lowest floor above ground level and higher
above ground level more than one full floor
(if single family, contents are rated throughout the building)
yes

no

If no, please describe:

ALL BUILDINGS: (CHECK ONE OF THE FIVE BLOCKS and record corresponding date in the date box)
BUILDING PERMIT DATE
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED IN A MOBILE HOME PARK
OR SUBDIVISION: CONSTRUCTION DATE OF MOBILE HOME PARK OR SUBDIVISION
DATE OF CONSTRUCTION
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED OUTSIDE A MOBILE HOME PARK OR
SUBSTANTIAL IMPROVEMENT DATE
SUBDIVISION: DATE OF PERMANENT PLACEMENT

DATE:
_______/_______/_______
(MM/DD/YYYY)

yes
no
IS BUILDING POST-FIRM CONSTRUCTION?
IF POST-FIRM CONSTRUCTION IN ZONES A, A1-A30, AE, AO, AH, V, V1-V30, VE, OR IF PRE-FIRM CONSTRUCTION IS ELEVATION RATED, attach certification.
Building Diagram Number
lowest adjacent grade (LAG)
Elevation certificate date
LOWEST FLOOR ELEVATION
(–) BASE FLOOD ELEVATION
(=) DIFFERENCE TO NEAREST FOOT
(+ OR –)
IN ZONES V AND V1-V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?
yes
no
IS BUILDING FLOOD-PROOFED?
(SEE FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)
BUILDING $

CONTENTS $

coverage

amount of
insurance

rate

Deductible buyback?

additional limits
(regular program only)

basic limits
coverage and rating

fax no.:

IS THIS BUILDING IN THE COURSE OF
yes
no
CONSTRUCTION?

Residential Condominium
Building Association policy
only: Total number of units
(include non-res.)
high-rise
low-rise

townhouse/rowhouse
(rcbap lowrise only)

DEDUCTIBLE:

signature

loan no.:
phone no.:

condo form of ownership?
yes
no
Condo coverage is for:
unit
entire building

1

is personal property household contents?

IF SECOND MORTGAGEE, LOSS PAYEE OR OTHER IS TO BE BILLED, COMPLETE
the following, INCLUDING THE NAME AND ADDRESS.
2ND MORTGAGEE
DISASTER AGENCY
LOSS PAYEE
IF OTHER, PLEASE SPECIFY:

IS BUILDING located on federal land?

Number of floors in entire
building (include basement/
enclosed area, if any) or
building type

contents located in:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level

IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. IF RURAL,
DESCRIBE PROPERTY LOCATION (DO NOT USE P.O. BOX).

Grandfathered?
yes
no
If yes,
Built in compliance?
Continuous coverage? Prior policy no.
Current COMMUNITY No./PANEL No. AND SUFFIX
—
Current FIRM zone
Current BFE

—

IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
BUILDING OCCUPANCY
SINGLE FAMILY
2-4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)

current policy number

New

annual
premium

amount of
insurance

rate

annual
premium

yes

yes

no

no

deductible

basic and
additional

prem. reduction/ increase

total amount
of insurance

total
premium

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

Rate type: (one building per policy—blanket coverage not permitted)
manual
submit for rating
alternative
v-zone risk Factor rating form
provisional rating
leased federal property
mortgage portfolio protection program

payment option:
credit card
other:

FEMA Form 086-0-1, AUG 09

$

icc premium
SUBTOTAL
%

CRS PREMIUM DISCOUNT

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY
FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE federal LAW.
see reverse side of copies 2, 3, & 4.

SIGNATURE OF INSURANCE AGENT/BROKER

ANNUAL SUBTOTAL

DATE (MM/DD/YYYY)

SUBTOTAL
probation surcharge

+

FEDERAL POLICY FEE

+

TOTAL PREPAID AMOUNt

Previously FEMA Form 81-16

PLEASE ATTACH TO NFIP COPY OF APPLICATION THE CHECK OR MONEY ORDER FOR
THE TOTAL PREPAID PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP — IMPORTANT

$

F-050 (8/09)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
National Flood Insurance Program
part 1 (of 2) of flood insurance application

Renewal

important—please print or type

policy
term

DIRECT BILL INSTRUCTIONS:
BILL INSURED
BILL SECOND
MORTGAGEE
BILL OTHER

POLICY PERIOD IS FROM
TO
12:01 A.M LOCAL TIME AT THE INSURED PROPERTY LOCATION
Waiting period:
 standard 30-day
map rev. (zone change from non-sfHa to sfHa)—one Day
loan—no waiting
Lender Required—No Waiting

BILL FIRST MORTGAGEE
BILL LOSS PAYEE

name, mailing Address, and telephone no. of insured:

insured
mail address

agent’s tax id:
fax no.:

is insurance required for disaster assistance?
If yes, check the government agency:
sba
other (specify):
enter case file number

yes
fema

no
fha

property
location

disaster
assistance

agent
information

Name, Address of licensed property or casualty insurance agent or broker:

agency no.:
phone no.:

community

2nd mortgageE/
Other

mortgageE

name and Address of first mortgagee

loan no.:
phone no.:

fax no.:

Rating map information
NAME OF COUNTY/PARISH
COMMUNITY No./PANEL No. AND SUFFIX
FIRM zone
COMMUNITY PROGRAm TYPE IS:
REGULAR

EMERGENCY

building
contents
construction data

yes

no

2

3 or more

split level

yes

no
BUILDING USE
Main house/building
Detached guest house
Detached garage
Agricultural building
Warehouse
Poolhouse, clubhouse,
recreation building
tool/storage shed

IS BUILDING walled and roofed?
yes
no
IS BUILDING over water?
no
partially
entirely

Other:

IS BUILDING elevated?
yes
no
If yes, area below is:
free of obstruction
with obstruction
if elevated, complete part 2
of application

ESTIMATED REPLACEMENT COST
amount $
IS BUILDING INSURED’S PRINCIPAL
RESIDENCE?
yes
no

FOR MANUFACTURED (MOBILE)
HOMEs/travel trailers,
complete part 2, section III.

lowest floor above ground level and higher
above ground level more than one full floor
(if single family, contents are rated throughout the building)
yes

no

If no, please describe:

ALL BUILDINGS: (CHECK ONE OF THE FIVE BLOCKS and record corresponding date in the date box)
BUILDING PERMIT DATE
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED IN A MOBILE HOME PARK
OR SUBDIVISION: CONSTRUCTION DATE OF MOBILE HOME PARK OR SUBDIVISION
DATE OF CONSTRUCTION
MANUFACTURED (MOBILE) HOMES/travel trailers LOCATED OUTSIDE A MOBILE HOME PARK OR
SUBSTANTIAL IMPROVEMENT DATE
SUBDIVISION: DATE OF PERMANENT PLACEMENT

DATE:
_______/_______/_______
(MM/DD/YYYY)

yes
no
IS BUILDING POST-FIRM CONSTRUCTION?
IF POST-FIRM CONSTRUCTION IN ZONES A, A1-A30, AE, AO, AH, V, V1-V30, VE, OR IF PRE-FIRM CONSTRUCTION IS ELEVATION RATED, attach certification.
Building Diagram Number
lowest adjacent grade (LAG)
Elevation certificate date
LOWEST FLOOR ELEVATION
(–) BASE FLOOD ELEVATION
(=) DIFFERENCE TO NEAREST FOOT
(+ OR –)
IN ZONES V AND V1-V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?
yes
no
IS BUILDING FLOOD-PROOFED?
(SEE FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)
BUILDING $

CONTENTS $

coverage

amount of
insurance

rate

Deductible buyback?

additional limits
(regular program only)

basic limits
coverage and rating

fax no.:

IS THIS BUILDING IN THE COURSE OF
yes
no
CONSTRUCTION?

Residential Condominium
Building Association policy
only: Total number of units
(include non-res.)
high-rise
low-rise

townhouse/rowhouse
BASEMENT, ENCLOSure, crawlspace
(rcbap lowrise only)
NONE
manufactured (mobile)
FINISHED basement/enclosure
home/travel trailer on
UNFINISHED basement/enclosure
foundation
crawlspace
IF NOT A SINGLE FAMILY DWELLING,
subgrade crawlspace
THE NUMBER OF OCCUPANCIES
(UNITS) IS

DEDUCTIBLE:

signature

loan no.:
phone no.:

condo form of ownership?
yes
no
Condo coverage is for:
unit
entire building

1

is personal property household contents?

IF SECOND MORTGAGEE, LOSS PAYEE OR OTHER IS TO BE BILLED, COMPLETE
the following, INCLUDING THE NAME AND ADDRESS.
2ND MORTGAGEE
DISASTER AGENCY
LOSS PAYEE
IF OTHER, PLEASE SPECIFY:

IS BUILDING located on federal land?

Number of floors in entire
building (include basement/
enclosed area, if any) or
building type

contents located in:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level

IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. IF RURAL,
DESCRIBE PROPERTY LOCATION (DO NOT USE P.O. BOX).

Grandfathered?
yes
no
If yes,
Built in compliance?
Continuous coverage? Prior policy no.
Current COMMUNITY No./PANEL No. AND SUFFIX
—
Current FIRM zone
Current BFE

—

IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
BUILDING OCCUPANCY
SINGLE FAMILY
2-4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)

current policy number

New

annual
premium

amount of
insurance

rate

annual
premium

yes

yes

no

no

deductible

basic and
additional

prem. reduction/ increase

total amount
of insurance

total
premium

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

Rate type: (one building per policy—blanket coverage not permitted)
manual
submit for rating
alternative
v-zone risk Factor rating form
provisional rating
leased federal property
mortgage portfolio protection program

payment option:
credit card
other:

FEMA Form 086-0-1, AUG 09

C
E
R
T
I
F
I
C
A
T
I
O
N
C
O
P
Y

$

icc premium
SUBTOTAL
%

CRS PREMIUM DISCOUNT

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY
FALSE STATEMENTS MAY BE PUNISHABLE BY FINE OR IMPRISONMENT UNDER APPLICABLE federal LAW.
see reverse side of copies 2, 3, & 4.

SIGNATURE OF INSURANCE AGENT/BROKER

ANNUAL SUBTOTAL

M
O
R
T
G
A
G
E
E

DATE (MM/DD/YYYY)

SUBTOTAL
probation surcharge

+

FEDERAL POLICY FEE

+

TOTAL PREPAID AMOUNt

Previously FEMA Form 81-16

PLEASE ATTACH TO NFIP COPY OF APPLICATION THE CHECK OR MONEY ORDER FOR
THE TOTAL PREPAID PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP — IMPORTANT

$

F-050 (8/09)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
part 2 (of 2) of flood insurance application

National Flood Insurance Program

ALL APPROPRIATE DATA PROVIDED BY THE INSURED OR OBTAINED FROM THE ELEVATION CERTIFICATE SHOULD BE REVIEWED AND
TRANSCRIBED BELOW. THIS PART OF THE APPLICATION MUST BE COMPLETED FOR ALL BUILDINGS.
current policy number
New
Renewal __________________________________________________

SECTION­­ I—ALL BUILDING TYPES
1.
2.

3.

4.

5.

6.

If yes, check the appropriate items:
Furnace
Heat pump
Air conditioner

Hot water heater
Fuel tank
Cistern

Elevator equipment
Washer & dryer
Food freezer

Other equipment or machinery servicing the building
7. Garage
a) Is the garage attached to or part of the building?
YES
NO
b) Total area of the garage: _________________ square feet.
c) Are there any openings (excluding doors) that are designed to
allow the passage of flood waters through the garage?
YES
NO
If yes, number of permanent openings (flood vents) within 1 foot
above the adjacent grade: ______. Total area of all permanent
openings (flood vents): ________ square inches.
d) Is the garage used solely for parking of vehicles, building
access, and/or storage?
YES
NO
e) Does the garage contain machinery or equipment?
YES
NO
If yes, check the appropriate items:

Furnace
Heat pump
Air conditioner

Hot water heater
Fuel tank
Cistern

Elevator equipment
Washer & dryer
Food freezer

Other equipment or machinery servicing the building
f) Does the garage have more than 20 linear feet of finished wall
paneling, etc?
YES
NO

Diagram number selected from Building Diagrams 1-9:
The lowest floor is (round to nearest foot):
feet
above
below (check one) the lowest ground
(grade) immediately next to the building.
The garage floor (if applicable) or elevated floor (if applicable) is
(round to nearest foot):
feet
above
below (check one) the lowest ground
(grade) immediately next to the building.
Machinery or equipment located at a level lower than the lowest
floor is (round to nearest foot):
feet below the lowest floor.
Site location
a) Approximate distance of site location to nearest shoreline:
Less than 200 feet
500 to 1,000 feet
200 to 500 feet
More than 1,000 feet
b) Source of flooding:
Ocean
River/stream
Lake
Other: _________________
Basement/Subgrade Crawlspace
a) Is the basement/subgrade crawlspace floor below grade on all
sides?
YES
NO
b) Does the basement/subgrade crawlspace contain machinery
or equipment?
YES
NO

SECTION­­II—elevated BUILDINGS

(Including Manufactured [Mobile] Homes/Travel Trailers)

8. Elevating foundation of the building:
Piers, posts, or piles

Reinforced masonry piers or concrete piers or columns

Reinforced concrete shear walls

Solid perimeter walls (Note: Not approved for elevating in
Zones VI-V30, VE, or V.)
9. Does the area below the elevated floor contain machinery or equipment?

YES
NO
If yes, check the appropriate items:

Furnace
Heat pump
Air conditioner

Hot water heater
Fuel tank
Cistern

Elevator equipment
Washer & dryer
Food freezer

Other equipment or machinery servicing the building
10. Area below the elevated floor:
a) Is the area below the elevated floor enclosed?
YES
NO
If yes, check one of the following:

Partially
Fully
If 10a is NO, do not answer 10b through 10f.
b) If enclosed, provide size of enclosed area/crawl space:
square feet.

c) Is the area below the elevated floor enclosed using materials
other than insect screening or light wood lattice?
YES
NO

If yes, check one of the following:
Breakaway walls
Solid wood frame walls
Masonry walls
Other:___________________________________________
d) Is the enclosed area/crawl space constructed with openings
(excluding doors) to allow the passage of flood waters through the
enclosed area?
YES
NO
If yes, number of permanent openings (flood vents) within 1 foot
above adjacent grade ______. Total Area of all permanent openings
(flood vents)
square inches
e) Is the enclosed area/crawl space used for any purpose other than
solely for parking of vehicles, building access, or storage?
YES
NO If yes, describe:_____________________________
___________________________________________________________
___________________________________________________________
f) Does the enclosed area/crawl space have more than 20 linear feet of
finished wall, paneling, etc?
YES
NO

SECTION­­ III—manufactured (mobile) homes/Travel trailers
14. The manufactured (mobile)
system utilizes:

Over-the-top ties

Frame ties

Frame connectors

11. Manufactured (mobile) home/travel trailer data:
Make:
Year of manufacture:
Model number:
Serial number:
12. Manufactured (mobile) home/travel trailer dimensions:
x
feet.
13. Are there any permanent additions or extensions to the manufactured
YES
NO
(mobile) home/travel trailer?
If yes, the dimensions are:

x

feet.

home/travel trailer anchoring
Ground anchors
Slab anchors
Other: _____________________________

15. The manufactured (mobile) home/travel trailer was installed in
accordance with:

Manufacturer’s specifications

Local floodplain management standards

State and/or local building standards
16. Is the manufactured (mobile) home/travel trailer located in a
manufactured (mobile) home park/subdivision?
YES
NO

the above statements are correct to the best of my knowledge. i understand that any false statements may be punishable
by fine or imprisonment under applicable federal law.

date (mm/dd/yyyy)

signature of insurance agent/broker

FEMA Form 086-0-1, AUG 09

Previously FEMA Form 81-16

F-050 (8/09)

FLOOD INSURANCE
FLOOD INSURANCE APPLICATION
FEMA FORM 086-0-1
NONDISCRIMINATION
No person or organization shall be excluded from participation in, denied the benefits of, or subjected to
discrimination under the Program authorized by the Act, on the grounds of race, color, creed, sex, age or
national origin.
PRIVACY ACT

The information requested is necessary to process your Flood Insurance Application for a flood insurance
policy. The authority to collect the information is Title 42, U.S. Code, Sections 4001 to 4028. Disclosures
of this information may be made: to federal, state, tribal, and local government agencies, fiscal agents,
your agent, mortgage servicing companies, insurance or other companies, lending institutions, and
contractors working for us, for the purpose of carrying out the National Flood Insurance Program; to
current Severe Repetitive Loss property owners and Preferred Risk Policy owners for the purpose of
property loss history evaluation; to the American Red Cross for verification of nonduplication of benefits
following a flooding event or disaster; to law enforcement agencies or professional organizations when
there may be a violation or potential violation of law; to a federal, state or local agency when we request
information relevant to an agency decision concerning issuance of a grant or other benefit, or in certain
circumstances when a federal agency requests such information for a similar purpose from us; to a
Congressional office in response to an inquiry made at the request of an individual; to the Office of
Management and Budget (OMB) in relation to private relief legislation under OMB Circular A-19; and to the
National Archives and Records Administration in records management inspections. Providing the
information is voluntary, but failure to do so may delay or prevent issuance of the flood insurance policy.
GENERAL

This information is provided pursuant to Public Law 96-511 (Paperwork Reduction Act of 1980, as
amended), dated December 11, 1980, to allow the public to participate more fully and meaningfully in the
Federal paperwork review process.
AUTHORITY

Public Law 96-511, amended, 44 U.S.C. 3507; and 5 CFR 1320.
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 12 minutes per response. The
burden estimate includes the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and submitting this form. You are not required to
respond to this collection of information unless a valid OMB control number is displayed on this form.
Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the
burden to: Information Collections Management, Department of Homeland Security, Federal Emergency
Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0006).
NOTE: Do not send your completed form to this address.