Form FEMA Form 086-0-1 FEMA Form 086-0-1 Flood Insurance Application

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency

O.M.B. No. 1660-0006 Expires August 31, 2013

National Flood Insurance Program

New

Flood Insurance Application, part 1 (of 2)

FIRST MORTGAGEE

other (AS SPECIFIED IN THE “2ND
MORTGAGEE/OTHER” BOX BELOW)

SECOND MORTGAGEE

agency no.:

agent’s tax id:

phone no.:

fax no.:

building
contents

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

1ST
mortgageE
loan no.:

is insurance required for disaster assistance?
sba
If yes, check the government agency:

yes
fema

2nd mortgageE/
Other

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:
no
fha

other (specify):
case file no.:

COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL (INCLUDING
HOTEL/MOTEL)
BUILDING PURPOSE

–
EMERGENCY

yes

If no, describe:

*if single family, contents are rated
throughout the building.

Building Diagram No.:

(IF POST-FIRM CONSTRUCTION IN ZONES A,
A1–A30, AE, AO, AH, V, V1–V30, VE, OR IF PREFIRM CONSTRUCTION IS ELEVATION RATED,
attach Elevation Certificate.)

LOWEST FLOOR ELEVATION:

Current BFE:

IS BUILDING INSURED’S Principal/PRIMARY RESIDENCE?
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, IS THE TENANT REQUESTING BUILDING COVERAGE?
IF YES, SEE NOTICE BELOW.
IS THE BUILDING A SEVERE REPETITIVE LOSS PROPERTY?

nO

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
/
CHECK ONE OF THE FOLLOWING:
BUILDING PERMIT
CONSTRUCTION
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED OUTSIDE A
MOBILE HOME PARK OR SUBDIVISION:
DATE OF PERMANENT PLACEMENT

no

yes

no
no

yes

no

with obstruction

/

/
(–) BASE FLOOD ELEVATION:

IS BUILDING FLOODPROOFED?

ESTIMATED BUILDING REPLACEMENT COST

yes

(=) DIFFERENCE TO NEAREST FOOT:

CONTENTS $

deductible

(regular program only)

annual
premium

(+ OR –)

no

no

additional limits

basic limits

yes

no (SEE the NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)

DEDUCTIBLE: BUILDING $
Deductible Buyback?
yes

(INCLUDING FOUNDATION): $

amount of
insurance

rate

annual
premium

total
premium

premium reduction/increase

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

manual

submit for rate

provisional rating

C
O
P
Y

SUBSTANTIAL IMPROVEMENT
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED IN A
MOBILE HOME PARK OR SUBDIVISION:
CONSTRUCTION DATE OF MOBILE HOME
PARK OR SUBDIVISION Facilities

IN ZONES V AND V1–V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?

Rate CATEGORY:

N
F
I
P

lowest adjacent grade (LAG):

Elevation certification date:

rate

yes

yes

DOES the BUILDING HAVE ANY ADDITIONS OR EXTENSIONS?
(ADDITIONS AND EXTENSIONS MAY BE SEPARATELY INSURED.)

no

is personal property household
contents?
yes
no

amount of
insurance

OTHER

IS BUILDING walled and roofed?
yes
no
IS BUILDING IN THE COURSE OF CONSTRUCTION?
yes
nO
IS BUILDING over water?
no
partially
entirely

Number of floors in building (includING basement/
enclosed area, if any) or building type
1
2
3 or more
split level
townhouse/rowhouse (RCBAP LOW-RISE ONLY)
manufactured (mobile) home/travel trailer on foundation

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no

TOTAL AMOUNT
OF INSURANCE

LOSS PAYEE

loan no.:

BASEMENT, ENCLOSure, crawlspace
NONE
FINISHED basement/enclosure
crawlspace
UNFINISHED basement/enclosure
subgrade crawlspace

contents located in*:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level
lowest floor above ground level
and higher
above ground level more than
1 full floor

2ND MORTGAGEE

Current FIRM zone:

100% RESIDENTIAL
100% NON-RESIDENTIAL
Is coverage for a condo unit?
yes
nO
MIXED-USE — SPECIFY PERCENTAGE
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
OF RESIDENTIAL USE:
%
TOTAL NUMBER OF UNITS:
IS BUILDING A BUSINESS PROPERTY?
HIGH-RISE
LOW-RISE
yes
no
IS BUILDING located on federal land?
yes

Insurance
coverage

NAME AND Mailing ADDRESS OF
IF OTHER, SPECIFY:

GRANDFATHERING information
Grandfathered?
yes
no
If yes,
Built in compliance or
CONTINUOUS COVERAGE (PROVIDE PRIOR POLICY NUMBER IN BOX ABOVE)
–
Current COMMUNITY No./PANEL No. AND SUFFIX:

Rating map information
NAME OF COUNTY/PARISH:

BUILDING OCCUPANCY

payment Method:
check
credit card
other:

notice: building coverage benefits — except for a residential condominium building — are not available if other nfip
building coverage has been purchased by the applicant or any other party for the same building.

signature

/

name and Mailing Address of first mortgagee:

construction
INFORMATION

property location
disaster
assistance
community

NOTE: One building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. If Rural, Enter Legal Description, or
Geographic Location of Property (Do Not Use P.O. Box).

/

standard 30-day
REQUIRED FOR LOAN Transaction — NO WAITING PERIOD
map revision (zone change from non-sfHa to sfHa) — 1 Day
TRANSFER (NFIP ONLY) — NO WAITING PERIOD

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

EMAIL ADDRESS:

Elevation
Data

Waiting period: 

insured
Information

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

coverage and rating

POLICY PERIOD IS FROM
TO
/
/
12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.

POLICY PERIOD

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

important—please print or type; Enter Dates as MM/DD/YYYY.
INSURED

Renewal

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE
BY FINE AND/OR IMPRISONMENT UNDER APPLICABLE federal LAW. see reverse side of copies 2, 3, and 4.
/

SIGNATURE OF INSURANCE AGENT/Producer DATE (MM/DD/YYYY)

/

ANNUAL SUBTOTAL

$

icc premium
SUBTOTAL
CRS PREMIUM DISCOUNT

%

SUBTOTAL
RESERVE FUND

%

SUBTOTAL
probation surcharge
FEDERAL POLICY FEE

/

SIGNATURE OF INSURED (OPTIONAL) DATE (MM/DD/YYYY)

FEMA Form 086-0-1

/

TOTAL AMOUNt Due

Previously FEMA Form 81-16
PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS APPLICATION.
IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP. — IMPORTANT

$
F-050 (Revised Aug 2010)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency

O.M.B. No. 1660-0006 Expires August 31, 2013

National Flood Insurance Program

New

Flood Insurance Application, part 1 (of 2)

FIRST MORTGAGEE

other (AS SPECIFIED IN THE “2ND
MORTGAGEE/OTHER” BOX BELOW)

SECOND MORTGAGEE

agency no.:

agent’s tax id:

phone no.:

fax no.:

building
contents

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

1ST
mortgageE
loan no.:

is insurance required for disaster assistance?
sba
If yes, check the government agency:

yes
fema

2nd mortgageE/
Other

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:
no
fha

other (specify):
case file no.:

COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL (INCLUDING
HOTEL/MOTEL)
BUILDING PURPOSE

–
EMERGENCY

yes

If no, describe:

*if single family, contents are rated
throughout the building.

Building Diagram No.:

(IF POST-FIRM CONSTRUCTION IN ZONES A,
A1–A30, AE, AO, AH, V, V1–V30, VE, OR IF PREFIRM CONSTRUCTION IS ELEVATION RATED,
attach Elevation Certificate.)

LOWEST FLOOR ELEVATION:

Current BFE:

IS BUILDING INSURED’S Principal/PRIMARY RESIDENCE?
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, IS THE TENANT REQUESTING BUILDING COVERAGE?
IF YES, SEE NOTICE BELOW.
IS THE BUILDING A SEVERE REPETITIVE LOSS PROPERTY?

nO

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
/
CHECK ONE OF THE FOLLOWING:
BUILDING PERMIT
CONSTRUCTION
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED OUTSIDE A
MOBILE HOME PARK OR SUBDIVISION:
DATE OF PERMANENT PLACEMENT

no

yes

no
no

yes

no

with obstruction

SUBSTANTIAL IMPROVEMENT
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED IN A
MOBILE HOME PARK OR SUBDIVISION:
CONSTRUCTION DATE OF MOBILE HOME
PARK OR SUBDIVISION Facilities

/

IS BUILDING FLOODPROOFED?

ESTIMATED BUILDING REPLACEMENT COST

yes

(=) DIFFERENCE TO NEAREST FOOT:

CONTENTS $

deductible

(regular program only)

annual
premium

(+ OR –)

no

no

additional limits

basic limits

yes

no (SEE the NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)

DEDUCTIBLE: BUILDING $
Deductible Buyback?
yes

(INCLUDING FOUNDATION): $

amount of
insurance

rate

annual
premium

total
premium

premium reduction/increase

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

manual

submit for rate

provisional rating

C
O
P
Y

/
(–) BASE FLOOD ELEVATION:

IN ZONES V AND V1–V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?

Rate CATEGORY:

A
G
E
N
T

lowest adjacent grade (LAG):

Elevation certification date:

rate

yes

yes

DOES the BUILDING HAVE ANY ADDITIONS OR EXTENSIONS?
(ADDITIONS AND EXTENSIONS MAY BE SEPARATELY INSURED.)

no

is personal property household
contents?
yes
no

amount of
insurance

OTHER

IS BUILDING walled and roofed?
yes
no
IS BUILDING IN THE COURSE OF CONSTRUCTION?
yes
nO
IS BUILDING over water?
no
partially
entirely

Number of floors in building (includING basement/
enclosed area, if any) or building type
1
2
3 or more
split level
townhouse/rowhouse (RCBAP LOW-RISE ONLY)
manufactured (mobile) home/travel trailer on foundation

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no

TOTAL AMOUNT
OF INSURANCE

LOSS PAYEE

loan no.:

BASEMENT, ENCLOSure, crawlspace
NONE
FINISHED basement/enclosure
crawlspace
UNFINISHED basement/enclosure
subgrade crawlspace

contents located in*:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level
lowest floor above ground level
and higher
above ground level more than
1 full floor

2ND MORTGAGEE

Current FIRM zone:

100% RESIDENTIAL
100% NON-RESIDENTIAL
Is coverage for a condo unit?
yes
nO
MIXED-USE — SPECIFY PERCENTAGE
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
OF RESIDENTIAL USE:
%
TOTAL NUMBER OF UNITS:
IS BUILDING A BUSINESS PROPERTY?
HIGH-RISE
LOW-RISE
yes
no
IS BUILDING located on federal land?
yes

Insurance
coverage

NAME AND Mailing ADDRESS OF
IF OTHER, SPECIFY:

GRANDFATHERING information
Grandfathered?
yes
no
If yes,
Built in compliance or
CONTINUOUS COVERAGE (PROVIDE PRIOR POLICY NUMBER IN BOX ABOVE)
–
Current COMMUNITY No./PANEL No. AND SUFFIX:

Rating map information
NAME OF COUNTY/PARISH:

BUILDING OCCUPANCY

payment Method:
check
credit card
other:

notice: building coverage benefits — except for a residential condominium building — are not available if other nfip
building coverage has been purchased by the applicant or any other party for the same building.

signature

/

name and Mailing Address of first mortgagee:

construction
INFORMATION

property location
disaster
assistance
community

NOTE: One building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. If Rural, Enter Legal Description, or
Geographic Location of Property (Do Not Use P.O. Box).

/

standard 30-day
REQUIRED FOR LOAN Transaction — NO WAITING PERIOD
map revision (zone change from non-sfHa to sfHa) — 1 Day
TRANSFER (NFIP ONLY) — NO WAITING PERIOD

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

EMAIL ADDRESS:

Elevation
Data

Waiting period: 

insured
Information

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

coverage and rating

POLICY PERIOD IS FROM
TO
/
/
12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.

POLICY PERIOD

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

important—please print or type; Enter Dates as MM/DD/YYYY.
INSURED

Renewal

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE
BY FINE AND/OR IMPRISONMENT UNDER APPLICABLE federal LAW. see reverse side of copies 2, 3, and 4.
/

SIGNATURE OF INSURANCE AGENT/Producer DATE (MM/DD/YYYY)

/

ANNUAL SUBTOTAL

$

icc premium
SUBTOTAL
CRS PREMIUM DISCOUNT

%

SUBTOTAL
RESERVE FUND

%

SUBTOTAL
probation surcharge
FEDERAL POLICY FEE

/

SIGNATURE OF INSURED (OPTIONAL) DATE (MM/DD/YYYY)

FEMA Form 086-0-1

/

TOTAL AMOUNt Due

Previously FEMA Form 81-16
PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS APPLICATION.
IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP. — IMPORTANT

$
F-050 (Revised Aug 2010)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency

O.M.B. No. 1660-0006 Expires August 31, 2013

National Flood Insurance Program

New

Flood Insurance Application, part 1 (of 2)

FIRST MORTGAGEE

other (AS SPECIFIED IN THE “2ND
MORTGAGEE/OTHER” BOX BELOW)

SECOND MORTGAGEE

agency no.:

agent’s tax id:

phone no.:

fax no.:

building
contents

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

1ST
mortgageE
loan no.:

is insurance required for disaster assistance?
sba
If yes, check the government agency:

yes
fema

2nd mortgageE/
Other

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:
no
fha

other (specify):
case file no.:

COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL (INCLUDING
HOTEL/MOTEL)
BUILDING PURPOSE

–
EMERGENCY

yes

If no, describe:

*if single family, contents are rated
throughout the building.

Building Diagram No.:

(IF POST-FIRM CONSTRUCTION IN ZONES A,
A1–A30, AE, AO, AH, V, V1–V30, VE, OR IF PREFIRM CONSTRUCTION IS ELEVATION RATED,
attach Elevation Certificate.)

LOWEST FLOOR ELEVATION:

Current BFE:

IS BUILDING INSURED’S Principal/PRIMARY RESIDENCE?
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, IS THE TENANT REQUESTING BUILDING COVERAGE?
IF YES, SEE NOTICE BELOW.
IS THE BUILDING A SEVERE REPETITIVE LOSS PROPERTY?

nO

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
/
CHECK ONE OF THE FOLLOWING:
BUILDING PERMIT
CONSTRUCTION
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED OUTSIDE A
MOBILE HOME PARK OR SUBDIVISION:
DATE OF PERMANENT PLACEMENT

no

yes

no
no

yes

no

with obstruction

SUBSTANTIAL IMPROVEMENT
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED IN A
MOBILE HOME PARK OR SUBDIVISION:
CONSTRUCTION DATE OF MOBILE HOME
PARK OR SUBDIVISION Facilities

/

IS BUILDING FLOODPROOFED?

ESTIMATED BUILDING REPLACEMENT COST

yes

(=) DIFFERENCE TO NEAREST FOOT:

CONTENTS $

deductible

(regular program only)

annual
premium

(+ OR –)

no

no

additional limits

basic limits

yes

no (SEE the NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)

DEDUCTIBLE: BUILDING $
Deductible Buyback?
yes

(INCLUDING FOUNDATION): $

amount of
insurance

rate

annual
premium

total
premium

premium reduction/increase

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

manual

submit for rate

provisional rating

C
O
P
Y

/
(–) BASE FLOOD ELEVATION:

IN ZONES V AND V1–V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?

Rate CATEGORY:

I
N
S
U
R
E
D

lowest adjacent grade (LAG):

Elevation certification date:

rate

yes

yes

DOES the BUILDING HAVE ANY ADDITIONS OR EXTENSIONS?
(ADDITIONS AND EXTENSIONS MAY BE SEPARATELY INSURED.)

no

is personal property household
contents?
yes
no

amount of
insurance

OTHER

IS BUILDING walled and roofed?
yes
no
IS BUILDING IN THE COURSE OF CONSTRUCTION?
yes
nO
IS BUILDING over water?
no
partially
entirely

Number of floors in building (includING basement/
enclosed area, if any) or building type
1
2
3 or more
split level
townhouse/rowhouse (RCBAP LOW-RISE ONLY)
manufactured (mobile) home/travel trailer on foundation

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no

TOTAL AMOUNT
OF INSURANCE

LOSS PAYEE

loan no.:

BASEMENT, ENCLOSure, crawlspace
NONE
FINISHED basement/enclosure
crawlspace
UNFINISHED basement/enclosure
subgrade crawlspace

contents located in*:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level
lowest floor above ground level
and higher
above ground level more than
1 full floor

2ND MORTGAGEE

Current FIRM zone:

100% RESIDENTIAL
100% NON-RESIDENTIAL
Is coverage for a condo unit?
yes
nO
MIXED-USE — SPECIFY PERCENTAGE
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
OF RESIDENTIAL USE:
%
TOTAL NUMBER OF UNITS:
IS BUILDING A BUSINESS PROPERTY?
HIGH-RISE
LOW-RISE
yes
no
IS BUILDING located on federal land?
yes

Insurance
coverage

NAME AND Mailing ADDRESS OF
IF OTHER, SPECIFY:

GRANDFATHERING information
Grandfathered?
yes
no
If yes,
Built in compliance or
CONTINUOUS COVERAGE (PROVIDE PRIOR POLICY NUMBER IN BOX ABOVE)
–
Current COMMUNITY No./PANEL No. AND SUFFIX:

Rating map information
NAME OF COUNTY/PARISH:

BUILDING OCCUPANCY

payment Method:
check
credit card
other:

notice: building coverage benefits — except for a residential condominium building — are not available if other nfip
building coverage has been purchased by the applicant or any other party for the same building.

signature

/

name and Mailing Address of first mortgagee:

construction
INFORMATION

property location
disaster
assistance
community

NOTE: One building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. If Rural, Enter Legal Description, or
Geographic Location of Property (Do Not Use P.O. Box).

/

standard 30-day
REQUIRED FOR LOAN Transaction — NO WAITING PERIOD
map revision (zone change from non-sfHa to sfHa) — 1 Day
TRANSFER (NFIP ONLY) — NO WAITING PERIOD

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

EMAIL ADDRESS:

Elevation
Data

Waiting period: 

insured
Information

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

coverage and rating

POLICY PERIOD IS FROM
TO
/
/
12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.

POLICY PERIOD

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

important—please print or type; Enter Dates as MM/DD/YYYY.
INSURED

Renewal

THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE
BY FINE AND/OR IMPRISONMENT UNDER APPLICABLE federal LAW. see reverse side of copies 2, 3, and 4.
/

SIGNATURE OF INSURANCE AGENT/Producer DATE (MM/DD/YYYY)

/

ANNUAL SUBTOTAL

$

icc premium
SUBTOTAL
CRS PREMIUM DISCOUNT

%

SUBTOTAL
RESERVE FUND

%

SUBTOTAL
probation surcharge
FEDERAL POLICY FEE

/

SIGNATURE OF INSURED (OPTIONAL) DATE (MM/DD/YYYY)

FEMA Form 086-0-1

/

TOTAL AMOUNt Due

Previously FEMA Form 81-16
PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS APPLICATION.
IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP. — IMPORTANT

$
F-050 (Revised Aug 2010)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency

O.M.B. No. 1660-0006 Expires August 31, 2013

National Flood Insurance Program

New

Flood Insurance Application, part 1 (of 2)

FIRST MORTGAGEE

other (AS SPECIFIED IN THE “2ND
MORTGAGEE/OTHER” BOX BELOW)

SECOND MORTGAGEE

agency no.:

agent’s tax id:

phone no.:

fax no.:

building
contents

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

1ST
mortgageE
loan no.:

is insurance required for disaster assistance?
sba
If yes, check the government agency:

yes
fema

2nd mortgageE/
Other

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:
no
fha

other (specify):
case file no.:

COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL (INCLUDING
HOTEL/MOTEL)
BUILDING PURPOSE

–
EMERGENCY

yes

If no, describe:

*if single family, contents are rated
throughout the building.

Building Diagram No.:

(IF POST-FIRM CONSTRUCTION IN ZONES A,
A1–A30, AE, AO, AH, V, V1–V30, VE, OR IF PREFIRM CONSTRUCTION IS ELEVATION RATED,
attach Elevation Certificate.)

LOWEST FLOOR ELEVATION:

Current BFE:

IS BUILDING INSURED’S Principal/PRIMARY RESIDENCE?
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, IS THE TENANT REQUESTING BUILDING COVERAGE?
IF YES, SEE NOTICE BELOW.
IS THE BUILDING A SEVERE REPETITIVE LOSS PROPERTY?

nO

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
/
CHECK ONE OF THE FOLLOWING:
BUILDING PERMIT
CONSTRUCTION
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED OUTSIDE A
MOBILE HOME PARK OR SUBDIVISION:
DATE OF PERMANENT PLACEMENT

no

yes

no
no

yes

no

with obstruction

SUBSTANTIAL IMPROVEMENT
FOR MANUFACTURED (MOBILE) HOMES/
travel trailers LOCATED IN A
MOBILE HOME PARK OR SUBDIVISION:
CONSTRUCTION DATE OF MOBILE HOME
PARK OR SUBDIVISION Facilities

lowest adjacent grade (LAG):

Elevation certification date:

/

/
(–) BASE FLOOD ELEVATION:

(=) DIFFERENCE TO NEAREST FOOT:

IN ZONES V AND V1–V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?
IS BUILDING FLOODPROOFED?

ESTIMATED BUILDING REPLACEMENT COST

yes

annual
premium

amount of
insurance

rate

deductible

annual
premium

total
premium

premium reduction/increase

building

.00

.00

.00

.00

contents

.00

.00

.00

.00

Rate CATEGORY:
manual

submit for rate

provisional rating

payment Method:
check
credit card
other:

notice: building coverage benefits — except for a residential condominium building — are not available if other nfip
building coverage has been purchased by the applicant or any other party for the same building.
THE ABOVE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY FALSE STATEMENTS MAY BE PUNISHABLE
BY FINE AND/OR IMPRISONMENT UNDER APPLICABLE federal LAW. see reverse side of copies 2, 3, and 4.
/

SIGNATURE OF INSURANCE AGENT/Producer DATE (MM/DD/YYYY)

/

ANNUAL SUBTOTAL

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

CONTENTS $

(regular program only)

M
O
R
T
G
A
G
E
E

(+ OR –)

no

no

additional limits

basic limits

yes

no (SEE the NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)

DEDUCTIBLE: BUILDING $
Deductible Buyback?
yes

(INCLUDING FOUNDATION): $

rate

yes

yes

DOES the BUILDING HAVE ANY ADDITIONS OR EXTENSIONS?
(ADDITIONS AND EXTENSIONS MAY BE SEPARATELY INSURED.)

no

is personal property household
contents?
yes
no

amount of
insurance

OTHER

IS BUILDING walled and roofed?
yes
no
IS BUILDING IN THE COURSE OF CONSTRUCTION?
yes
nO
IS BUILDING over water?
no
partially
entirely

Number of floors in building (includING basement/
enclosed area, if any) or building type
1
2
3 or more
split level
townhouse/rowhouse (RCBAP LOW-RISE ONLY)
manufactured (mobile) home/travel trailer on foundation

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no

TOTAL AMOUNT
OF INSURANCE

LOSS PAYEE

loan no.:

BASEMENT, ENCLOSure, crawlspace
NONE
FINISHED basement/enclosure
crawlspace
UNFINISHED basement/enclosure
subgrade crawlspace

contents located in*:
Basement/enclosure
Basement/enclosure and above
lowest floor only above ground level
lowest floor above ground level
and higher
above ground level more than
1 full floor

2ND MORTGAGEE

Current FIRM zone:

100% RESIDENTIAL
100% NON-RESIDENTIAL
Is coverage for a condo unit?
yes
nO
MIXED-USE — SPECIFY PERCENTAGE
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
OF RESIDENTIAL USE:
%
TOTAL NUMBER OF UNITS:
IS BUILDING A BUSINESS PROPERTY?
HIGH-RISE
LOW-RISE
yes
no
IS BUILDING located on federal land?
yes

Insurance
coverage

NAME AND Mailing ADDRESS OF
IF OTHER, SPECIFY:

GRANDFATHERING information
Grandfathered?
yes
no
If yes,
Built in compliance or
CONTINUOUS COVERAGE (PROVIDE PRIOR POLICY NUMBER IN BOX ABOVE)
–
Current COMMUNITY No./PANEL No. AND SUFFIX:

Rating map information
NAME OF COUNTY/PARISH:

BUILDING OCCUPANCY

signature

/

name and Mailing Address of first mortgagee:

construction
INFORMATION

property location
disaster
assistance
community

NOTE: One building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED’s MAILING ADDRESS?
YES
NO IF NO, ENTER PROPERTY ADDRESS. If Rural, Enter Legal Description, or
Geographic Location of Property (Do Not Use P.O. Box).

/

standard 30-day
REQUIRED FOR LOAN Transaction — NO WAITING PERIOD
map revision (zone change from non-sfHa to sfHa) — 1 Day
TRANSFER (NFIP ONLY) — NO WAITING PERIOD

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

EMAIL ADDRESS:

Elevation
Data

Waiting period: 

insured
Information

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

coverage and rating

POLICY PERIOD IS FROM
TO
/
/
12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.

POLICY PERIOD

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

important—please print or type; Enter Dates as MM/DD/YYYY.
INSURED

Renewal

$

icc premium
SUBTOTAL
CRS PREMIUM DISCOUNT

%

SUBTOTAL
RESERVE FUND

%

SUBTOTAL
probation surcharge
FEDERAL POLICY FEE

/

SIGNATURE OF INSURED (OPTIONAL) DATE (MM/DD/YYYY)

FEMA Form 086-0-1

/

TOTAL AMOUNt Due

Previously FEMA Form 81-16
PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS APPLICATION.
IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP. — IMPORTANT

$
F-050 (Revised Aug 2010)

U.S. DEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency

O.M.B. No. 1660-0006 Expires August 31, 2013

National Flood Insurance Program

Flood Insurance APPLICATION, PART 2 (OF 2)

ALL DATA PROVIDED BY THE INSURED OR OBTAINED FROM THE ELEVATION
CERTIFICATE SHOULD BE REVIEWED AND TRANSCRIBED BELOW. THIS PART OF
THE APPLICATION MUST BE COMPLETED FOR ALL BUILDINGS.

New

Renewal

Transfer (NFIP ONLY)

Prior policy #:

SECTION­­ I – ALL BUILDING TYPES

1. Building Use:

Main house/building
Detached guest house
Agricultural building
Warehouse
Poolhouse, clubhouse, recreation building
O ther:

Detached garage
Tool/storage shed

3. Basement/Subgrade Crawlspace

2. Garage
a) Is there a garage attached to or part of the building?
YES
NO

b) Total area of the garage:

c) Are there any openings (excluding doors) that are designed to allow the
YES
NO
passage of floodwaters through the garage?

a) Is the basement/subgrade crawlspace floor below grade on all sides?
YES
NO

b) If yes, does the basement/subgrade crawlspace contain machinery and/or
equipment?
YES
NO

square feet.

d) Is the garage used solely for parking of vehicles, building
YES
NO
access, and/or storage?

e) Does the garage contain machinery and/or equipment?

Furnace
Heat pump
Air conditioner
Water heater
Fuel tank
Cistern
Elevator equipment
Washer & dryer
Food freezer
Other machinery and/or equipment servicing the building (describe):

4. Additions and Extensions (if Applicable)
Coverage is for:
Building including addition(s) and extension(s)

YES

Building excluding addition(s) and extension(s)
Provide policy number for addition or extension:

NO

If yes, check the applicable items:

If yes, check the applicable items:

If yes, number of permanent flood openings within 1 foot
. Total area of all permanent
above the adjacent grade:
square inches.
openings:

If the answer to 1a is YES, answer 1b through 1f.

f) Does the garage have more than 20 linear feet of finished interior wall,
YES
NO
paneling, etc.?

Addition or extension only (include description in the Property Location
box in Part 1)
Provide policy number for building excluding addition(s) or extension(s):

Furnace
Heat pump
Air conditioner
Water heater
Fuel tank
Cistern
Elevator equipment
Washer & dryer
Food freezer
Other machinery and/or equipment servicing the building (describe):

SECTION­­ II – elevated BUILDINGS
(Including Manufactured [Mobile] Homes/Travel Trailers)

1. Elevating Foundation Type

Solid wood frame walls (non-breakaway)
Masonry walls (if breakaway, submit certification documentation)
Masonry walls (non-breakaway)

Piers, posts, or piles
Reinforced masonry piers or concrete piers or columns
Reinforced concrete shear walls
S
 olid foundation walls (Note: Not approved for elevating in
Zones V1–V30, VE, or V.)

Other (describe):

d) If enclosed with a material other than insect screening or light wood
lattice, provide size of enclosed area:

2. Machinery and Equipment Below the Elevated Floor

Does the area below the elevated floor contain machinery
and/or equipment?
YES
NO
If yes, check the applicable items:

vehicles, building access, and/or storage?

Furnace
Heat pump
Air conditioner
Water heater
Fuel tank
Cistern
Elevator equipment
Washer & dryer
Food freezer
Other machinery and/or equipment servicing the building (describe):

a) Is the area below the elevated floor enclosed?

If yes, check one of the following:

finished interior wall, paneling, etc.?

Fully

YES

NO

Partially

b) Does the area below the elevated floor contain elevators?

YES

NO

YES

NO

a) Is the enclosed area/crawlspace constructed with openings
(excluding doors) to allow the passage of floodwaters through the
YES
NO
enclosed area?
If yes, indicate number of permanent flood openings within 1 foot

If yes, how many?

above adjacent grade:

If the answer to 3a or 3b is YES, answer 3c through 4b.

NO

4. Flood Openings

3. Area Below the Elevated Floor

YES

If yes, describe:

f) D
 oes the enclosed area have more than 20 linear feet of

square feet.

e) Is the enclosed area used for any purpose other than solely for parking of

c) Indicate material used for enclosure:
Insect screening
Light wood lattice
Solid wood frame walls (if breakaway, submit certification documentation)

.

Total area of all permanent flood openings:
square inches.

b) Are flood openings engineered?
YES

NO If yes, submit certification.

SECTION­­ III – manufactured (mobile) homes/Travel trailers
(Wheels must be removed for travel trailer to be insurable.)

1. Manufactured (Mobile) Home/Travel Trailer Data

2. Anchoring

Year of manufacture:

Make:

Model number:

×

Ground anchors
Slab anchors
Other (describe):

If yes, the dimensions are:

3. Installation

feet

Are there any permanent additions and/or extensions?

Over-the-top ties
Frame ties
Frame connectors

Serial number:
Dimensions:

The manufactured (mobile) home/travel trailer anchoring
system utilizes: (Check all that apply.)

×

YES
feet

NO

The manufactured (mobile) home/travel trailer was installed in
accordance with: (Check all that apply.)
Manufacturer’s specifications
Local floodplain management standards
State and/or local building standards

the above statements are correct to the best of my knowledge. i understand that any false statements may be punishable
by fine AND/or imprisonment under applicable federal law.

/

/

signature of insurance agent/Producer date (mm/dd/yyyy)

/

/

SIGNATURE OF INSURED (OPTIONAL) date (mm/dd/yyyy)

FEMA Form 086-0-1

Previously FEMA Form 81-16

F-050 (Revised Aug 2010)

National Flood Insurance Program

FLOOD INSURANCE APPLICATION
FEMA FORM 086-0-1
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 form is estimated to average 12 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 the form. This collection of information is
required to obtain or retain benefits. You are not required to respond to this collection of information
unless a valid OMB control number is displayed in the upper right corner of 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,
1800 South Bell Street, Arlington VA 20598-3005, Paperwork Reduction Project (1660-0033).
NOTE: Do not send your completed form to this address.