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pdfU.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program
O.M.B. No. 1660-0006 Expires August 31, 2012
FLOOD INSURANCE GENERAL CHANGE ENDORSEMENT
POLICY
TERM
IMPORTANT - PLEASE PRINT OR TYPE
YES
A
NO
INSURED MAIL
ADDRESS
ADDRESS CHANGE
AGENCY NO: ________________________
AGENTS TAX ID # :
__________________
NEW AGENT
YES
NO
PHONE NO:__________________ FAX NO:___________________ IF YES, THE INSURED MUST SIGN THIS FORM
?
PROPERTY
LOCATION
DISASTER
ASSISTANCE
AGENT
INFORMATION
ENDORSEMENT EFFECTIVE DATE: _____________________ (FOR ADDED COVERAGE , DETERMINE THE APPROPRIATE WAITING PERIOD)
NAME, ADDRESS OF LICENSED PROPERTY OR CASUALTY
INSURANCE AGENT OR BROKER :
OTHER (SPECIFY): _________________________
COMMUNITY
FIRST
MORTGAGEE
2ND MORTGAGEE/OTHER
THE LOCATION OF INSURED PROPERTY CANNOT BE CHANGED BY ENDORSEMENT
A NEW APPLICATION IS REQUIRED.
RATING MAP INFORMATION
?
NAME OF COUNTY/ PARISH _____________________________
COMMUNITY NO. / PANEL NO. AND SUFFIX _____________ ________________
CURRENT
FIRM ZONE ______________
CURRENT FIRM ZONE
COMMUNITY PROGRAM TYPE IS:
REGULAR
EMERGENCY
IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
IS BUILDING LOCATED ON FEDERAL LAND?
?
BUILT IN COMPLIANCE?
IF YES,
PRIOR POLICY NO. ______________
CURRENT BFE
CONDO FORM OF OWNERSHIP?
BUILDING USE:
MAIN HOUSE/BUILDING
CONDO COVERAGE IS FOR:
DETACHED GUEST HOUSE
BUILDING
DETACHED GARAGE
AGRICULTURAL BUILDING
:
BASEMENT/ENCLOSURE/
CRAWLSPACE
WAREHOUSE
POOLHOUSE, CLUBHOUSE,
RECREATION BUILDING
NO
ONLY :
TOOL/STORAGE SHED
N
F
I
P
OTHER : _____________________
______________
IF ELEVATED, COMPLETE PART 2 OF
THE FLOOD INSURANCE APPLICATION.
CONTENTS
RESIDENCE?
FOR MANUFACTURED (MOBILE)
HOMES / TRAVEL TRAILERS,
COMPLETE PART 2, SECTION III
OF THE FLOOD INSURANCE
APPLICATION.
C
O
P
Y
CONSTRUCTION DATA
TE
OUTSIDE
BUILDING DIAGRAM NUMBER
ELEVATION CERTIFICATION DATE
SEE FLOOD INSURANCE
MANUAL FOR
CERTIFICATION FORM
CONTENTS $ ________________________
SIGNATURE
COVERAGE AND RATING
DEDUCTIBLE: BUILDING $ ___________________
LOWEST ADJACENT GRADE (LAG)
DATE
FEMA Form 086-0-3, AUG 09
Previously FEMA Form 81-18
F-051 (8/09)
PLEASE ATTACH TO NFIP COPY OF ENDORSEMENT THE CHECK OR MONEY ORDER FOR THE
TOTAL ADDITIONAL PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK TO ORIGINAL, AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS. GIVE THIRD COPY TO INSURED, AND FOURTH COPY TO MORTGAGEE.
U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program
O.M.B. No. 1660-0006 Expires August 31, 2012
FLOOD INSURANCE GENERAL CHANGE ENDORSEMENT
POLICY
TERM
IMPORTANT - PLEASE PRINT OR TYPE
YES
A
NO
INSURED MAIL
ADDRESS
ADDRESS CHANGE
AGENCY NO: ________________________
AGENTS TAX ID # :
__________________
NEW AGENT
YES
NO
PHONE NO:__________________ FAX NO:___________________ IF YES, THE INSURED MUST SIGN THIS FORM
?
PROPERTY
LOCATION
DISASTER
ASSISTANCE
AGENT
INFORMATION
ENDORSEMENT EFFECTIVE DATE: _____________________ (FOR ADDED COVERAGE , DETERMINE THE APPROPRIATE WAITING PERIOD)
NAME, ADDRESS OF LICENSED PROPERTY OR CASUALTY
INSURANCE AGENT OR BROKER :
OTHER (SPECIFY): _________________________
COMMUNITY
FIRST
MORTGAGEE
2ND MORTGAGEE/OTHER
THE LOCATION OF INSURED PROPERTY CANNOT BE CHANGED BY ENDORSEMENT
A NEW APPLICATION IS REQUIRED.
RATING MAP INFORMATION
?
NAME OF COUNTY/ PARISH _____________________________
COMMUNITY NO. / PANEL NO. AND SUFFIX _____________ ________________
CURRENT
FIRM ZONE ______________
CURRENT FIRM ZONE
COMMUNITY PROGRAM TYPE IS:
REGULAR
EMERGENCY
IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
IS BUILDING LOCATED ON FEDERAL LAND?
?
BUILT IN COMPLIANCE?
IF YES,
PRIOR POLICY NO. ______________
CURRENT BFE
CONDO FORM OF OWNERSHIP?
BUILDING USE:
MAIN HOUSE/BUILDING
CONDO COVERAGE IS FOR:
DETACHED GUEST HOUSE
BUILDING
DETACHED GARAGE
AGRICULTURAL BUILDING
:
BASEMENT/ENCLOSURE/
CRAWLSPACE
WAREHOUSE
POOLHOUSE, CLUBHOUSE,
RECREATION BUILDING
NO
ONLY :
TOOL/STORAGE SHED
OTHER : _____________________
______________
IF ELEVATED, COMPLETE PART 2 OF
THE FLOOD INSURANCE APPLICATION.
CONTENTS
RESIDENCE?
FOR MANUFACTURED (MOBILE)
HOMES / TRAVEL TRAILERS,
COMPLETE PART 2, SECTION III
OF THE FLOOD INSURANCE
APPLICATION.
A
G
E
N
T
C
O
P
Y
CONSTRUCTION DATA
TE
OUTSIDE
BUILDING DIAGRAM NUMBER
ELEVATION CERTIFICATION DATE
SEE FLOOD INSURANCE
MANUAL FOR
CERTIFICATION FORM
CONTENTS $ ________________________
SIGNATURE
COVERAGE AND RATING
DEDUCTIBLE: BUILDING $ ___________________
LOWEST ADJACENT GRADE (LAG)
DATE
FEMA Form 086-0-3, AUG 09
Previously FEMA Form 81-18
F-051 (8/09)
PLEASE ATTACH TO NFIP COPY OF ENDORSEMENT THE CHECK OR MONEY ORDER FOR THE
TOTAL ADDITIONAL PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK TO ORIGINAL, AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS. GIVE THIRD COPY TO INSURED, AND FOURTH COPY TO MORTGAGEE.
U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program
O.M.B. No. 1660-0006 Expires August 31, 2012
FLOOD INSURANCE GENERAL CHANGE ENDORSEMENT
POLICY
TERM
IMPORTANT - PLEASE PRINT OR TYPE
YES
A
NO
INSURED MAIL
ADDRESS
ADDRESS CHANGE
AGENCY NO: ________________________
AGENTS TAX ID # :
__________________
NEW AGENT
YES
NO
PHONE NO:__________________ FAX NO:___________________ IF YES, THE INSURED MUST SIGN THIS FORM
?
PROPERTY
LOCATION
DISASTER
ASSISTANCE
AGENT
INFORMATION
ENDORSEMENT EFFECTIVE DATE: _____________________ (FOR ADDED COVERAGE , DETERMINE THE APPROPRIATE WAITING PERIOD)
NAME, ADDRESS OF LICENSED PROPERTY OR CASUALTY
INSURANCE AGENT OR BROKER :
OTHER (SPECIFY): _________________________
COMMUNITY
FIRST
MORTGAGEE
2ND MORTGAGEE/OTHER
THE LOCATION OF INSURED PROPERTY CANNOT BE CHANGED BY ENDORSEMENT
A NEW APPLICATION IS REQUIRED.
RATING MAP INFORMATION
?
NAME OF COUNTY/ PARISH _____________________________
COMMUNITY NO. / PANEL NO. AND SUFFIX _____________ ________________
CURRENT
FIRM ZONE ______________
CURRENT FIRM ZONE
COMMUNITY PROGRAM TYPE IS:
REGULAR
EMERGENCY
IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
IS BUILDING LOCATED ON FEDERAL LAND?
?
BUILT IN COMPLIANCE?
IF YES,
PRIOR POLICY NO. ______________
CURRENT BFE
CONDO FORM OF OWNERSHIP?
BUILDING USE:
MAIN HOUSE/BUILDING
CONDO COVERAGE IS FOR:
DETACHED GUEST HOUSE
BUILDING
DETACHED GARAGE
AGRICULTURAL BUILDING
:
BASEMENT/ENCLOSURE/
CRAWLSPACE
WAREHOUSE
POOLHOUSE, CLUBHOUSE,
RECREATION BUILDING
NO
ONLY :
TOOL/STORAGE SHED
OTHER : _____________________
______________
IF ELEVATED, COMPLETE PART 2 OF
THE FLOOD INSURANCE APPLICATION.
CONTENTS
RESIDENCE?
FOR MANUFACTURED (MOBILE)
HOMES / TRAVEL TRAILERS,
COMPLETE PART 2, SECTION III
OF THE FLOOD INSURANCE
APPLICATION.
CONSTRUCTION DATA
TE
I
N
S
U
R
E
D
C
O
P
Y
OUTSIDE
BUILDING DIAGRAM NUMBER
ELEVATION CERTIFICATION DATE
SEE FLOOD INSURANCE
MANUAL FOR
CERTIFICATION FORM
CONTENTS $ ________________________
SIGNATURE
COVERAGE AND RATING
DEDUCTIBLE: BUILDING $ ___________________
LOWEST ADJACENT GRADE (LAG)
DATE
FEMA Form 086-0-3, AUG 09
Previously FEMA Form 81-18
F-051 (8/09)
PLEASE ATTACH TO NFIP COPY OF ENDORSEMENT THE CHECK OR MONEY ORDER FOR THE
TOTAL ADDITIONAL PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK TO ORIGINAL, AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS. GIVE THIRD COPY TO INSURED, AND FOURTH COPY TO MORTGAGEE.
U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program
O.M.B. No. 1660-0006 Expires August 31, 2012
FLOOD INSURANCE GENERAL CHANGE ENDORSEMENT
POLICY
TERM
IMPORTANT - PLEASE PRINT OR TYPE
YES
A
NO
INSURED MAIL
ADDRESS
ADDRESS CHANGE
AGENCY NO: ________________________
AGENTS TAX ID # :
__________________
NEW AGENT
YES
NO
PHONE NO:__________________ FAX NO:___________________ IF YES, THE INSURED MUST SIGN THIS FORM
?
PROPERTY
LOCATION
DISASTER
ASSISTANCE
AGENT
INFORMATION
ENDORSEMENT EFFECTIVE DATE: _____________________ (FOR ADDED COVERAGE , DETERMINE THE APPROPRIATE WAITING PERIOD)
NAME, ADDRESS OF LICENSED PROPERTY OR CASUALTY
INSURANCE AGENT OR BROKER :
OTHER (SPECIFY): _________________________
COMMUNITY
FIRST
MORTGAGEE
2ND MORTGAGEE/OTHER
THE LOCATION OF INSURED PROPERTY CANNOT BE CHANGED BY ENDORSEMENT
A NEW APPLICATION IS REQUIRED.
RATING MAP INFORMATION
?
NAME OF COUNTY/ PARISH _____________________________
COMMUNITY NO. / PANEL NO. AND SUFFIX _____________ ________________
CURRENT
FIRM ZONE ______________
CURRENT FIRM ZONE
COMMUNITY PROGRAM TYPE IS:
REGULAR
EMERGENCY
IS INSURED BUILDING OWNED BY STATE GOVERNMENT?
IS BUILDING LOCATED ON FEDERAL LAND?
?
BUILT IN COMPLIANCE?
IF YES,
PRIOR POLICY NO. ______________
CURRENT BFE
CONDO FORM OF OWNERSHIP?
BUILDING USE:
MAIN HOUSE/BUILDING
CONDO COVERAGE IS FOR:
DETACHED GUEST HOUSE
BUILDING
DETACHED GARAGE
AGRICULTURAL BUILDING
:
BASEMENT/ENCLOSURE/
CRAWLSPACE
WAREHOUSE
POOLHOUSE, CLUBHOUSE,
RECREATION BUILDING
NO
ONLY :
TOOL/STORAGE SHED
OTHER : _____________________
______________
IF ELEVATED, COMPLETE PART 2 OF
THE FLOOD INSURANCE APPLICATION.
FOR MANUFACTURED (MOBILE)
HOMES / TRAVEL TRAILERS,
COMPLETE PART 2, SECTION III
OF THE FLOOD INSURANCE
APPLICATION.
CONTENTS
RESIDENCE?
CONSTRUCTION DATA
TE
OUTSIDE
BUILDING DIAGRAM NUMBER
ELEVATION CERTIFICATION DATE
SEE FLOOD INSURANCE
MANUAL FOR
CERTIFICATION FORM
CONTENTS $ ________________________
C
E
R
T
I
F
I
C
A
T
I
O
N
C
O
P
Y
SIGNATURE
COVERAGE AND RATING
DEDUCTIBLE: BUILDING $ ___________________
LOWEST ADJACENT GRADE (LAG)
M
O
R
T
G
A
G
E
E
DATE
FEMA Form 086-0-3, AUG 09
Previously FEMA Form 81-18
F-051 (8/09)
PLEASE ATTACH TO NFIP COPY OF ENDORSEMENT THE CHECK OR MONEY ORDER FOR THE
TOTAL ADDITIONAL PREMIUM MADE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK TO ORIGINAL, AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS. GIVE THIRD COPY TO INSURED, AND FOURTH COPY TO MORTGAGEE.
FLOOD INSURANCE
GENERAL CHANGE ENDORSEMENT
FEMA FORM 086-0-3
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
contractorsworking 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 9 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.
| File Type | application/pdf |
| File Title | F-051_ChanEndor_pg1_19Aug |
| File Modified | 2010-05-13 |
| File Created | 2009-08-19 |