Form FEMA Form 086-0-5 FEMA Form 086-0-5 Flood Insurance Preferred Risk Policy Application

U.S. Department of Homeland Security
Federal Emergency Management Agency
National Flood Insurance Program
FLOOD INSURANCE PrefeRred Risk Policy Application

Important – Please Print Or Type

Policy
Term

Direct bill instructions:

Waiting Period:

Insured’s
Mailing Address

No

SBA

FHA

FEMA

Other (specify) _______________________________

Second Mortgagee/Other

Yes

Loan TRANSACTION – No waiting

Name, TELEPHONE NUMBER, and mailing address of insured:

PHONE NO.: _______________________
FAX NO.: _______________________
AGENcy no.: _________________________________________________________
Agent’s tax id: ______________________________________________________
is insurance required for disaster assistance?
If yes, check the government agency:

Standard 30-day

12:01 A.M. local time at the insured property location

Case file number: _________________________________________________

Name, TELEphone no., fax no., and address of first mortgagee including
loan NUMBER:

if second mortgagee, loss payee or other is to be billed, the
following must be completed, including the name, telephone no.,
fax no., and address.

2nd mortgagee
Loss payee

disaster agency, specify ____________________
other (specify) ______________________________

loan NO.: _________________________________________
PHONE NO.: ______________________

FAX NO.: _______________________

name of county/parish: _____________________________________
community number and suffix for location of property insured: ____________

Loan Number: _________________________________________________

_________________ Flood insurance rate map zonE ______________________

Community

Agent
Information
disaster
assistance
First
mortgagee
Property
Location
building

If new, leave blank

Policy Period is from ______________________ to _________________________

Bill
Bill
Bill
Bill
Bill
Insured First Second Loss Other

Mortgagee Mortgagee Payee
NAME, address, TELEphone no., and fax no. of licensed property or
casualty insurance agent or broker:

Is insured location same as insured mailing address?
Yes
No
If no, enter property address. if rural, describe property location.
(do not use p.o. box)

information source:
community official
flood map
mortgagee
other (specify): ____________________________________________________
IS BUILDING LOCATED ON FEDERAL LAND?

building occupancy:
Single Family
2-4 Family
OTHER Residential
NON-Residential
(INCL. HOTEL/MOTEL)

Insured’s Principal residence?

Yes

Contents Located In:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
BASEMENT/ENCLOSURE AND ABOVE
LOWEST FLOOR ONLY ABOVE
GROUND LEVEL
LOWEST FLOOR ABOVE GROUND
LEVEL AND HIGHER FLOORS
ABOVE GROUND LEVEL MORE THAN
ONE FULL FLOOR

NO

Building type (including basement/enclosure):
One floor
Split level
two floors
three or more floors
MAnufactured (mobile) home/travel
traILER on foundation

Yes

No

ESTIMATED REPLACEMENT COST
amount $ _________________
Building use:
 ain house/building
m
detached guest house
detached garage
agricultural building
warehouse
poolhouse, clubhouse, rec. bldg.
tool/storage shed
Other: _________________________

construction Date
_____ /_____ /______
CONDO FORM OF OWNERSHIP?
Yes
NO
Yes
NO
Coverage for Condo Unit?
Building permit date
Yes
NO
Townhouse/rowhouse condo unit?
Date of Construction
Substantial IMPR. DATE
manufactured (mobile) homes/travel trailers located in a mobile home park or subdivision: Construction date of mobile home park or subdivision facilities
manufactured (mobile) homes/travel trailers located outside a mobile home park or subdivision: date of permanent placement

the following conditions should be used to determine a building’s eligibility for a prp.

TWO (2) loss payments, each more than $1,000

Yes

No

THREE (3) or more loss payments, regardless of amount

Yes

No

Two (2) Federal disaster relief payments, each more than $1,000

Yes

No

Three (3) Federal disaster relief payments, regardless of amount

Yes

No

One (1) flood insurance claim payment and One (1) flood disaster
relief payment (including loans and grants), each more than $1,000

Yes

No

C
O
P
Y

BUILDING AND CONTENTS COVERAGE COMBINATION
BUILDING: $

Premium

B) do any of these conditions, arising from one or more occurences, exist?

BASEMENT, ENCLOSURE,
CRAWLSPACE
NONE
FINISHED BASEMENT/
ENCLOSURE
UNFINISHED BASEMENT/
ENCLOSURE
crawlspace
Subgrade crawlspace

N
F
I
P

Enter selected option froM the premium tables
in the flood insurance manual

A) is the building located in a special flood hazard area on a flood hazard boundary map,
or on a flood insurance rate map zone a, ae, a1-a30, ao, ah, a99, v, ve,
v1-V30, ar, ar dual zones AR/AE, AR/AH, AR/AO, AR/A1-A30, AR/A?
Yes
No

Notice

Current Policy Number
NEW
RENEWAL FL ________________________________

CONTENTS: $
PREMIUM: $

CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

Signature

INsurance is available under this application only if the answers to these questions are no

(one Building per policy – blanket coverage not permitted)
The above statements are correct to the best of my knowledge. the property owner and I understand
that any false statements may be punishable by fine or imprisonment under applicable federal law.
signature of insurance agent/broker _________________________________________________________________________ date ________________________

(MM/DD/YYYY)

FEMA Form 086-0-5, AUG 09

Previously FEMA Form 81-67 F-089 (8/09)

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.
Special note to insurance agent: Send original to NFIP, Keep second copy for your records, give third copy to the insured, and fourth copy to mortgagee.

U.S. Department of Homeland Security
Federal Emergency Management Agency
National Flood Insurance Program
FLOOD INSURANCE PrefeRred Risk Policy Application

Important – Please Print Or Type

Policy
Term

Direct bill instructions:

Waiting Period:

Insured’s
Mailing Address

No

SBA

FHA

FEMA

Other (specify) _______________________________

Second Mortgagee/Other

Yes

Loan TRANSACTION – No waiting

Name, TELEPHONE NUMBER, and mailing address of insured:

PHONE NO.: _______________________
FAX NO.: _______________________
AGENcy no.: _________________________________________________________
Agent’s tax id: ______________________________________________________
is insurance required for disaster assistance?
If yes, check the government agency:

Standard 30-day

12:01 A.M. local time at the insured property location

Case file number: _________________________________________________

Name, TELEphone no., fax no., and address of first mortgagee including
loan NUMBER:

if second mortgagee, loss payee or other is to be billed, the
following must be completed, including the name, telephone no.,
fax no., and address.

2nd mortgagee
Loss payee

disaster agency, specify ____________________
other (specify) ______________________________

loan NO.: _________________________________________
PHONE NO.: ______________________

FAX NO.: _______________________

name of county/parish: _____________________________________
community number and suffix for location of property insured: ____________

Loan Number: _________________________________________________

_________________ Flood insurance rate map zonE ______________________

Community

Agent
Information
disaster
assistance
First
mortgagee
Property
Location
building

If new, leave blank

Policy Period is from ______________________ to _________________________

Bill
Bill
Bill
Bill
Bill
Insured First Second Loss Other

Mortgagee Mortgagee Payee
NAME, address, TELEphone no., and fax no. of licensed property or
casualty insurance agent or broker:

Is insured location same as insured mailing address?
Yes
No
If no, enter property address. if rural, describe property location.
(do not use p.o. box)

information source:
community official
flood map
mortgagee
other (specify): ____________________________________________________
IS BUILDING LOCATED ON FEDERAL LAND?

building occupancy:
Single Family
2-4 Family
OTHER Residential
NON-Residential
(INCL. HOTEL/MOTEL)

Insured’s Principal residence?

Yes

Contents Located In:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
BASEMENT/ENCLOSURE AND ABOVE
LOWEST FLOOR ONLY ABOVE
GROUND LEVEL
LOWEST FLOOR ABOVE GROUND
LEVEL AND HIGHER FLOORS
ABOVE GROUND LEVEL MORE THAN
ONE FULL FLOOR

NO

Building type (including basement/enclosure):
One floor
Split level
two floors
three or more floors
MAnufactured (mobile) home/travel
traILER on foundation

Yes

the following conditions should be used to determine a building’s eligibility for a prp.

ESTIMATED REPLACEMENT COST
amount $ _________________
Building use:
 ain house/building
m
detached guest house
detached garage
agricultural building
warehouse
poolhouse, clubhouse, rec. bldg.
tool/storage shed
Other: _________________________

TWO (2) loss payments, each more than $1,000

Yes

No

THREE (3) or more loss payments, regardless of amount

Yes

No

Two (2) Federal disaster relief payments, each more than $1,000

Yes

No

Three (3) Federal disaster relief payments, regardless of amount

Yes

No

One (1) flood insurance claim payment and One (1) flood disaster
relief payment (including loans and grants), each more than $1,000

Yes

No

BASEMENT, ENCLOSURE,
CRAWLSPACE
NONE
FINISHED BASEMENT/
ENCLOSURE
UNFINISHED BASEMENT/
ENCLOSURE
crawlspace
Subgrade crawlspace

C
O
P
Y

Enter selected option froM the premium tables
in the flood insurance manual
BUILDING AND CONTENTS COVERAGE COMBINATION
BUILDING: $

Premium

B) do any of these conditions, arising from one or more occurences, exist?

A
G
E
N
T

No

construction Date
_____ /_____ /______
CONDO FORM OF OWNERSHIP?
Yes
NO
Yes
NO
Coverage for Condo Unit?
Building permit date
Yes
NO
Townhouse/rowhouse condo unit?
Date of Construction
Substantial IMPR. DATE
manufactured (mobile) homes/travel trailers located in a mobile home park or subdivision: Construction date of mobile home park or subdivision facilities
manufactured (mobile) homes/travel trailers located outside a mobile home park or subdivision: date of permanent placement

A) is the building located in a special flood hazard area on a flood hazard boundary map,
or on a flood insurance rate map zone a, ae, a1-a30, ao, ah, a99, v, ve,
v1-V30, ar, ar dual zones AR/AE, AR/AH, AR/AO, AR/A1-A30, AR/A?
Yes
No

Notice

Current Policy Number
NEW
RENEWAL FL ________________________________

CONTENTS: $
PREMIUM: $

CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

Signature

INsurance is available under this application only if the answers to these questions are no

(one Building per policy – blanket coverage not permitted)
The above statements are correct to the best of my knowledge. the property owner and I understand
that any false statements may be punishable by fine or imprisonment under applicable federal law.
signature of insurance agent/broker _________________________________________________________________________ date ________________________

(MM/DD/YYYY)

FEMA Form 086-0-5, AUG 09

Previously FEMA Form 81-67 F-089 (8/09)

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.
Special note to insurance agent: Send original to NFIP, Keep second copy for your records, give third copy to the insured, and fourth copy to mortgagee.

U.S. Department of Homeland Security
Federal Emergency Management Agency
National Flood Insurance Program
FLOOD INSURANCE PrefeRred Risk Policy Application

Important – Please Print Or Type

Policy
Term

Direct bill instructions:

Waiting Period:

Insured’s
Mailing Address

No

SBA

FHA

FEMA

Other (specify) _______________________________

Second Mortgagee/Other

Yes

Loan TRANSACTION – No waiting

Name, TELEPHONE NUMBER, and mailing address of insured:

PHONE NO.: _______________________
FAX NO.: _______________________
AGENcy no.: _________________________________________________________
Agent’s tax id: ______________________________________________________
is insurance required for disaster assistance?
If yes, check the government agency:

Standard 30-day

12:01 A.M. local time at the insured property location

Case file number: _________________________________________________

Name, TELEphone no., fax no., and address of first mortgagee including
loan NUMBER:

if second mortgagee, loss payee or other is to be billed, the
following must be completed, including the name, telephone no.,
fax no., and address.

2nd mortgagee
Loss payee

disaster agency, specify ____________________
other (specify) ______________________________

loan NO.: _________________________________________
PHONE NO.: ______________________

FAX NO.: _______________________

name of county/parish: _____________________________________
community number and suffix for location of property insured: ____________

Loan Number: _________________________________________________

_________________ Flood insurance rate map zonE ______________________

Community

Agent
Information
disaster
assistance
First
mortgagee
Property
Location
building

If new, leave blank

Policy Period is from ______________________ to _________________________

Bill
Bill
Bill
Bill
Bill
Insured First Second Loss Other

Mortgagee Mortgagee Payee
NAME, address, TELEphone no., and fax no. of licensed property or
casualty insurance agent or broker:

Is insured location same as insured mailing address?
Yes
No
If no, enter property address. if rural, describe property location.
(do not use p.o. box)

information source:
community official
flood map
mortgagee
other (specify): ____________________________________________________
IS BUILDING LOCATED ON FEDERAL LAND?

building occupancy:
Single Family
2-4 Family
OTHER Residential
NON-Residential
(INCL. HOTEL/MOTEL)

Insured’s Principal residence?

Yes

Contents Located In:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
BASEMENT/ENCLOSURE AND ABOVE
LOWEST FLOOR ONLY ABOVE
GROUND LEVEL
LOWEST FLOOR ABOVE GROUND
LEVEL AND HIGHER FLOORS
ABOVE GROUND LEVEL MORE THAN
ONE FULL FLOOR

NO

Building type (including basement/enclosure):
One floor
Split level
two floors
three or more floors
MAnufactured (mobile) home/travel
traILER on foundation

Yes

No

ESTIMATED REPLACEMENT COST
amount $ _________________
Building use:
 ain house/building
m
detached guest house
detached garage
agricultural building
warehouse
poolhouse, clubhouse, rec. bldg.
tool/storage shed
Other: _________________________

construction Date
_____ /_____ /______
CONDO FORM OF OWNERSHIP?
Yes
NO
Yes
NO
Coverage for Condo Unit?
Building permit date
Yes
NO
Townhouse/rowhouse condo unit?
Date of Construction
Substantial IMPR. DATE
manufactured (mobile) homes/travel trailers located in a mobile home park or subdivision: Construction date of mobile home park or subdivision facilities
manufactured (mobile) homes/travel trailers located outside a mobile home park or subdivision: date of permanent placement

the following conditions should be used to determine a building’s eligibility for a prp.

TWO (2) loss payments, each more than $1,000

Yes

No

THREE (3) or more loss payments, regardless of amount

Yes

No

Two (2) Federal disaster relief payments, each more than $1,000

Yes

No

Three (3) Federal disaster relief payments, regardless of amount

Yes

No

One (1) flood insurance claim payment and One (1) flood disaster
relief payment (including loans and grants), each more than $1,000

Yes

No

C
O
P
Y

BUILDING AND CONTENTS COVERAGE COMBINATION
BUILDING: $

Premium

B) do any of these conditions, arising from one or more occurences, exist?

BASEMENT, ENCLOSURE,
CRAWLSPACE
NONE
FINISHED BASEMENT/
ENCLOSURE
UNFINISHED BASEMENT/
ENCLOSURE
crawlspace
Subgrade crawlspace

I
N
S
U
R
E
D

Enter selected option froM the premium tables
in the flood insurance manual

A) is the building located in a special flood hazard area on a flood hazard boundary map,
or on a flood insurance rate map zone a, ae, a1-a30, ao, ah, a99, v, ve,
v1-V30, ar, ar dual zones AR/AE, AR/AH, AR/AO, AR/A1-A30, AR/A?
Yes
No

Notice

Current Policy Number
NEW
RENEWAL FL ________________________________

CONTENTS: $
PREMIUM: $

CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

Signature

INsurance is available under this application only if the answers to these questions are no

(one Building per policy – blanket coverage not permitted)
The above statements are correct to the best of my knowledge. the property owner and I understand
that any false statements may be punishable by fine or imprisonment under applicable federal law.
signature of insurance agent/broker _________________________________________________________________________ date ________________________

(MM/DD/YYYY)

FEMA Form 086-0-5, AUG 09

Previously FEMA Form 81-67 F-089 (8/09)

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.
Special note to insurance agent: Send original to NFIP, Keep second copy for your records, give third copy to the insured, and fourth copy to mortgagee.

U.S. Department of Homeland Security
Federal Emergency Management Agency
National Flood Insurance Program
FLOOD INSURANCE PrefeRred Risk Policy Application

Important – Please Print Or Type

Policy
Term

Direct bill instructions:

Waiting Period:

Insured’s
Mailing Address

No

SBA

FHA

FEMA

Other (specify) _______________________________

Second Mortgagee/Other

Yes

Loan TRANSACTION – No waiting

Name, TELEPHONE NUMBER, and mailing address of insured:

PHONE NO.: _______________________
FAX NO.: _______________________
AGENcy no.: _________________________________________________________
Agent’s tax id: ______________________________________________________
is insurance required for disaster assistance?
If yes, check the government agency:

Standard 30-day

12:01 A.M. local time at the insured property location

Case file number: _________________________________________________

Name, TELEphone no., fax no., and address of first mortgagee including
loan NUMBER:

if second mortgagee, loss payee or other is to be billed, the
following must be completed, including the name, telephone no.,
fax no., and address.

2nd mortgagee
Loss payee

disaster agency, specify ____________________
other (specify) ______________________________

loan NO.: _________________________________________
PHONE NO.: ______________________

Loan Number: _________________________________________________

_________________ Flood insurance rate map zonE ______________________

Is insured location same as insured mailing address?
Yes
No
If no, enter property address. if rural, describe property location.
(do not use p.o. box)

information source:
community official
flood map
mortgagee
other (specify): ____________________________________________________
IS BUILDING LOCATED ON FEDERAL LAND?

building occupancy:
Single Family
2-4 Family
OTHER Residential
NON-Residential
(INCL. HOTEL/MOTEL)

Insured’s Principal residence?

Yes

Contents Located In:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
BASEMENT/ENCLOSURE AND ABOVE
LOWEST FLOOR ONLY ABOVE
GROUND LEVEL
LOWEST FLOOR ABOVE GROUND
LEVEL AND HIGHER FLOORS
ABOVE GROUND LEVEL MORE THAN
ONE FULL FLOOR

NO

Building type (including basement/enclosure):
One floor
Split level
two floors
three or more floors
MAnufactured (mobile) home/travel
traILER on foundation

Yes

No

ESTIMATED REPLACEMENT COST
amount $ _________________
Building use:
 ain house/building
m
detached guest house
detached garage
agricultural building
warehouse
poolhouse, clubhouse, rec. bldg.
tool/storage shed
Other: _________________________

construction Date
_____ /_____ /______
CONDO FORM OF OWNERSHIP?
Yes
NO
Yes
NO
Coverage for Condo Unit?
Building permit date
Yes
NO
Townhouse/rowhouse condo unit?
Date of Construction
Substantial IMPR. DATE
manufactured (mobile) homes/travel trailers located in a mobile home park or subdivision: Construction date of mobile home park or subdivision facilities
manufactured (mobile) homes/travel trailers located outside a mobile home park or subdivision: date of permanent placement

the following conditions should be used to determine a building’s eligibility for a prp.

TWO (2) loss payments, each more than $1,000

Yes

No

THREE (3) or more loss payments, regardless of amount

Yes

No

Two (2) Federal disaster relief payments, each more than $1,000

Yes

No

Three (3) Federal disaster relief payments, regardless of amount

Yes

No

One (1) flood insurance claim payment and One (1) flood disaster
relief payment (including loans and grants), each more than $1,000

Yes

No

BUILDING AND CONTENTS COVERAGE COMBINATION

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

BUILDING: $

Premium

B) do any of these conditions, arising from one or more occurences, exist?

BASEMENT, ENCLOSURE,
CRAWLSPACE
NONE
FINISHED BASEMENT/
ENCLOSURE
UNFINISHED BASEMENT/
ENCLOSURE
crawlspace
Subgrade crawlspace

Enter selected option froM the premium tables
in the flood insurance manual

A) is the building located in a special flood hazard area on a flood hazard boundary map,
or on a flood insurance rate map zone a, ae, a1-a30, ao, ah, a99, v, ve,
v1-V30, ar, ar dual zones AR/AE, AR/AH, AR/AO, AR/A1-A30, AR/A?
Yes
No

M
O
R
T
G
A
G
E
E

FAX NO.: _______________________

name of county/parish: _____________________________________
community number and suffix for location of property insured: ____________
Community

Agent
Information
disaster
assistance
First
mortgagee
Property
Location
building

If new, leave blank

Policy Period is from ______________________ to _________________________

Bill
Bill
Bill
Bill
Bill
Insured First Second Loss Other

Mortgagee Mortgagee Payee
NAME, address, TELEphone no., and fax no. of licensed property or
casualty insurance agent or broker:

Notice

Current Policy Number
NEW
RENEWAL FL ________________________________

CONTENTS: $
PREMIUM: $

CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

C
O
P
Y

Signature

INsurance is available under this application only if the answers to these questions are no

(one Building per policy – blanket coverage not permitted)
The above statements are correct to the best of my knowledge. the property owner and I understand
that any false statements may be punishable by fine or imprisonment under applicable federal law.
signature of insurance agent/broker _________________________________________________________________________ date ________________________

(MM/DD/YYYY)

FEMA Form 086-0-5, AUG 09

Previously FEMA Form 81-67 F-089 (8/09)

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.
Special note to insurance agent: Send original to NFIP, Keep second copy for your records, give third copy to the insured, and fourth copy to mortgagee.

FLOOD INSURANCE
PREFERRED RISK POLICY APPLICATION
FEMA FORM 086-0-5
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 8 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.