Form 086-0-07 Building - Worksheet

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM

O.M.B. No. 1660-0005
Expires September 30, 2010

WORKSHEET - BUILDING

See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice
INSURED AND LOCATION

DATE OF REPORT
POLICY NO. FL

ADJUSTING FIRM AND ADDRESS

ADJUSTER

MEASURE DIMENSIONS AND DRAW DIAGRAM OF GROUND FLOOR
AREA. ATTACH SNAPSHOT

Type Of Building

Adjuster's File No.

Date of Loss

Age

Building Dimensions

Total Sq. Ft.

No. Rooms

Type of Foundation

Finished Basement

No. Stories

Yes
Interior Wall Construction

No

Exterior Wall Construction

No. Baths

Estimated Replacement Cost
Less Depreciation
Actual Cash Value
Quantity

FEMA Form 086-0-7, OCT 07

Detailed Description

Full Cost Repair

REPLACES ALL PREVIOUS EDITIONS.

Depreciation

Flood Loss

Wind Loss
(If any)

F-099

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 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 the collection of information titled Claims for National Flood Insurance Program (NFIP) is estimated to average 6 hours 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 these forms. You are not required to respond to this collection of information unless a currently valid OMB control number and
expiration date is displayed in the upper right corner of the these forms. Send comments regarding the accuracy of the burden estimate and suggestions for
reducing the burden to: Information Collections Management, 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.
FEMA Form No.
086-0-6
086-0-7
086-0-8
086-0-9
086-0-10
086-0-11
086-0-12
086-0-13
086-0-14
086-0-15
086-0-16
086-0-17
086-0-18
086-0-19
086-0-20
086-0-21

Title
Worksheet-Contents-Personal Property
Worksheet-Building
Worksheet-Building (Continued)
Proof of Loss
Increased Cost of Compliance
Notice of Loss
Statement as to Full Cost to Repair or Replacement
Cost Coverage, Subject to the Terms and Conditions
of this Policy
National Flood Insurance Program Preliminary Report
National Flood Insurance Program Final Report
National Flood Insurance Program Narrative Report
Cause of Loss and Subrogation Report
Manufactured (Mobile) Home/Travel Trailer Worksheet
Mobile Home/Travel Trailer Worksheet (Continued)
Increased Cost of Compliance (ICC) Adjuster Report
Adjuster Preliminary Damage Assessment
Adjuster Certification Application

Burden Hours
2.5 Hours
2.5 Hours
1.0 Hours
.08 Hours
2.0 Hours
.07 Hours
.10 Hours
.07 Hours
.07 Hours
.08 Hours
1 Hour
.50 Hours
.25 Hours
.42 Hours
.25 Hours
.25 Hours