Form 086-0-14 National Flood Insurance Program Final Report

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

O.M.B. No. 1660-0005
Expires September 30, 2010
See reverse side for Privacy Act Statement
and Paperwork Burden Disclosure Notice

THE NFIP REQUIRES THAT A PRELIMINARY REPORT BE RECEIVED WITHIN 15 DAYS OF ASSIGNMENT,
AND AN INTERIM OR FINAL REPORT NOT LATER THAN EVERY 30 DAYS THEREAFTER.

FINAL REPORT

INSURED

POLICY NUMBER

PROPERTY ADDRESS

DATE OF LOSS

ADJUSTING COMPANY

ADJ. FILE NO.
Insured at premises since:

Date risk was originally constructed:

PREMISES HISTORY

Date of Alteration

Brief Description of Alteration

Market Value

Cost of Alteration

Repair

Type of Alteration
Recon.

Improv.

*Substantial Improvement?
Yes
No

Repair

Recon.

Improv.

Yes

No

Repair

Recon.

Improv.

Yes

No

* Defined as any repair, reconstruction, or improvement; the cost of which equals or exceeds 50% of the market value of the structure before the damage occurred or the reconstruction
or improvement was begun.
Prior losses (approximate dates and amounts of loss):
Yes
No
Yes
No
Insured but no claim made
Insured?
Repairs completed?
Repairs completed?
Repairs completed?

Yes
Yes

No

Insured?

Yes

No

Insured but no claim made

No

Insured?

Yes

No

Insured but no claim made

INTEREST

(Continue under Remarks if additional space is needed for alteration or prior losses.)
Mortgagee(s):
Loss Payee(s):
Other Insurance:

(Company)
Duration building will not be habitable:
0-2 days

(Type)
(Policy Number)
3-7 days
1-2 months
2-4 weeks
Claim Recapitulation (See worksheet for details)

CLAIM SUMMARY

Building

(Covers Bldg./Conts.)
more than 2 months
Contents

No
Yes
(Covers flood?)

Totals

Covered Damage (ACV)
Removal/Protection
Total Loss (ACV)
Less Salvage
Less Deductible
Excess Over Limit
Claims Payable (ACV)
Identify Cause:
Yes

CERTIFICATION

ENCL EXCLUDED DAMAGES

Main building RCV: $
*Includes mobile home.
Excluded
Building
Damages:

Less than 1,000
1,000 - 2,000
2,000 - 5, 000

Excluded
Contents
Damages:

Less than - 1, 000
1,000 - 2, 000
2,000 - 5, 000

No

Not applicable

Total buildiing claim: $

If yes, R/C claim: $
5,000 - 10,000
10,000 - 20,000
More than 20,000

Less than 1,000
1,000 - 2, 000
2,000 - 5, 000

5,000 - 10,000
10,000 - 20,000
More than 20,000

5,000 - 10, 000
10,000 - 20, 000
More than 20, 000
(
)
pp)

Less than - 1, 000
1,000 - 2, 000
2,000 - 5, 000

5,000 - 10, 000
10,000 - 20, 000
More than 20, 000

Building worksheets
(
)
Photographs
Proof of Loss
Other
Narrative (
Contents worksheets: (
)
Other
R/C Proof
The above statments are true and correct to the best of knowledge. I understand that any false statements may be punishable by fine or imprisonment under 18 U.S. Code Sec. 1001.
Insured
County of
Insured

State of
Signed this

day of

Date of Report
FEMA Form 086-0-14, OCT 07

, 20

Witness

Adjuster's Signature
REPLACES ALL PREVIOUS EDITIONS

Adjuster's FC Number

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