Form 086-0-11 Notice of Loss

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

NOTICE OF LOSS

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

NATIONAL FLOOD
INSURANCE PROGRAM

(See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice)
1. NAME OF SERVICING OFFICE

7. POLICY NUMBER

8. POLICY PERIOD (From, To)

2. AGENCY NAME AND MAILING ADDRESS (Rubber stamp or type)

9. DATE OF LOSS

10. KIND OF LOSS

11. Probable Amount of Loss-All
Perils
$
10. KIND OF LOSS
No
Yes

12. Estimate of Loss-this Policy

Flood

3. INSURED

Mudslide

$
Buildings

Contents

14. REMARKS: BRIEF DESCRIPTION OF DAMAGE (If
emergency handling required, explain why)

4. PROPERTY

PHONE NUMBER

5. MAIL ADDRESS

PHONE NUMBER

6. LOCATION OF PROPERTY IF REMOVED FOR PROTECTION
15. DESCRIPTION OF PROPERTY COVERED
AMOUNT
ITEM
DESCRIPTION
INSURANCE
NO.
1
Bldg.

on
the

Family

Story building of

Basement

Yes

Construction.
No

$

On the contents in the Building described above
2
Conts.

$

or in the

Family

Building of
Basement

16. MORTGAGE (Building)

17. LOSS PAYEE (Contents)

Story
Construction.

No
Yes
18. List any other insurance applicable to the property described in item 15 above including: Homeowners, Wind and/or excess policy; Coverage on specifically
described articles, e.g., Furs, Jewelry, etc. Please provide policy numbers as applicable.

CATASTROPHE SERIAL NO.

19.

CAT. ZONE NO.

DATED

COPIES
SENT TO
20. Name of Adjuster To Whom this Notice Has Been Forwarded

21. Name of Adjuster Handling E/C or Other Insurance Loss

THIS SPACE FOR USE BY SERVICING OFFICE

The Standard Flood Insurance Policy is subject to the National Flood Insurance Act of 1968, and any Acts Amendatory thereof, and Regulations
issued by the Federal Insurance Administration pursuant to such statute(s).
FEMA Form 086-0-11, OCT 07

REPLACES ALL PREVIOUS EDITIONS.

F-102

1.
2.
3.
4.
5.

INSTRUCTIONS FOR AGENTS OR BROKERS
Complete this Notice of Loss in its entirety. DO NOT OMIT ANY INFORMATION.
Forward the completed notice to NFIP shown on the Declarations Sheet of the Policy.
All losses under Flood Policies will b e assigned to adjusters by NFIP.
Agents and Brokers are not permitted to adjust losses under Flood Policies.
Additional Flood Notices of Loss may be obtained from:
FEMA/MAP Services Center
P.O. Box 1038
Jessup, MD 20794-1038
1-800-358-9616

INSTRUCTIONS FOR ADJUSTERS:
1. Obtain necessary forms for the adjustment of Flood Losses from NFIP assigning the loss.
2. Preliminary reports and estimates must be submitted to NFIP not later than ten working days from the date of assignment.
3. Preliminary reports must indicate the height of the water, to the nearest foot, above or below the first floor level of the risk involved.
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