Form FEMA Form 086-0-2 FEMA Form 086-0-2 Flood Insurance Cancellation/Nullification Request Form

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 CANCELLATION/NULLIFICATION REQUEST FORM

POLICY #:

Policy
Period

Important – Please Print Or Type; Enter Dates as MM/DD/YYYY.

Policy Period is from

/

to

/

/

/

Cancellation Effective Date:

agency no.:

agent’s tax id:

phone no.:

fax no.:

EMAIL ADDRESS:

1sT
mortgagee

NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:

NAME AND MAILING ADDRESS OF INSURED FOR MAILING REFUND:

PHONE NO.:

Property Location

Insured property location:

Loan No.:
2nd mortgageE / 
Other

/

Insured Information

Agent/Producer
Information

NAME AND MAILING ADDRESS OF AGENT/PRODUCER ON THE POLICY BEING CANCELED.

/

NAME AND MAILING ADDRESS OF OTHER PARTIES NOTIFIED:

10. CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP
12. MORTGAGE PAID OFF

CANCELLATION REASON CODE:

N
F
I
P

REFUND

CanceLlation Reason CODES

13. VOIDANCE PRIOR TO EFFECTIVE DATE
14. VOIDANCE DUE TO CREDIT CARD ERROR

1. BUILDING SOLD OR REMOVED

15. INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

2. CONTENTS SOLD OR REMOVED
3. POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON
EXPIRATION DATE WITH OTHER INSURANCE COVERAGE

16. DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP
18. MORTGAGE PAID OFF ON MPPP POLICY

4. DUPLICATE NFIP POLICIES

19. INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR

5. NON-PAYMENT
6. RISK NOT ELIGIBLE FOR COVERAGE
7.

PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

20. POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE LOSS PROPERTY)
21. OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

8. POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED
BY MORTGAGEE AS PROPERTY NOT IN SFHA

22. CANCEL/REWRITE DUE TO MISRATING

9. INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

24. CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

23. FRAUD (FEMA APPROVAL REQUIRED)

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE OR AT request of insured)

C
O
P
Y

Signature

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 INSURED Date (MM / DD / YYYY)
(NOT REQUIRED FOR REASON 5, 6, OR 22)

/

/
/
signature of other insured Date (MM / DD / YYYY)

FEMA Form 086-0-2

/
/
SIGNATURE OF AGENT/Producer Date (MM / DD / YYYY)

Previously FEMA Form 81-17

F-052 (Revised Aug 2010)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT/Producer: 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

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

National Flood Insurance Program

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM

POLICY #:

Policy
Period

Important – Please Print Or Type; Enter Dates as MM/DD/YYYY.

Policy Period is from

/

to

/

/

/

Cancellation Effective Date:

agency no.:

agent’s tax id:

phone no.:

fax no.:

EMAIL ADDRESS:

1sT
mortgagee

NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:

NAME AND MAILING ADDRESS OF INSURED FOR MAILING REFUND:

PHONE NO.:

Property Location

Insured property location:

Loan No.:
2nd mortgageE / 
Other

/

Insured Information

Agent/Producer
Information

NAME AND MAILING ADDRESS OF AGENT/PRODUCER ON THE POLICY BEING CANCELED.

/

NAME AND MAILING ADDRESS OF OTHER PARTIES NOTIFIED:

10. CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP
12. MORTGAGE PAID OFF

CANCELLATION REASON CODE:

A
G
E
N
T

REFUND

CanceLlation Reason CODES

13. VOIDANCE PRIOR TO EFFECTIVE DATE
14. VOIDANCE DUE TO CREDIT CARD ERROR

1. BUILDING SOLD OR REMOVED

15. INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

2. CONTENTS SOLD OR REMOVED
3. POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON
EXPIRATION DATE WITH OTHER INSURANCE COVERAGE

16. DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP
18. MORTGAGE PAID OFF ON MPPP POLICY

4. DUPLICATE NFIP POLICIES

19. INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR

5. NON-PAYMENT
6. RISK NOT ELIGIBLE FOR COVERAGE
7.

PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

20. POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE LOSS PROPERTY)
21. OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

8. POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED
BY MORTGAGEE AS PROPERTY NOT IN SFHA

22. CANCEL/REWRITE DUE TO MISRATING

9. INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

24. CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

23. FRAUD (FEMA APPROVAL REQUIRED)

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE OR AT request of insured)

C
O
P
Y

Signature

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 INSURED Date (MM / DD / YYYY)
(NOT REQUIRED FOR REASON 5, 6, OR 22)

/

/
/
signature of other insured Date (MM / DD / YYYY)

FEMA Form 086-0-2

/
/
SIGNATURE OF AGENT/Producer Date (MM / DD / YYYY)

Previously FEMA Form 81-17

F-052 (Revised Aug 2010)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT/Producer: 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

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

National Flood Insurance Program

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM

POLICY #:

Policy
Period

Important – Please Print Or Type; Enter Dates as MM/DD/YYYY.

Policy Period is from

/

to

/

/

/

Cancellation Effective Date:

agency no.:

agent’s tax id:

phone no.:

fax no.:

EMAIL ADDRESS:

1sT
mortgagee

NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:

NAME AND MAILING ADDRESS OF INSURED FOR MAILING REFUND:

PHONE NO.:

Property Location

Insured property location:

Loan No.:
2nd mortgageE / 
Other

/

Insured Information

Agent/Producer
Information

NAME AND MAILING ADDRESS OF AGENT/PRODUCER ON THE POLICY BEING CANCELED.

/

NAME AND MAILING ADDRESS OF OTHER PARTIES NOTIFIED:

10. CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP
12. MORTGAGE PAID OFF

CANCELLATION REASON CODE:

REFUND

CanceLlation Reason CODES

13. VOIDANCE PRIOR TO EFFECTIVE DATE
14. VOIDANCE DUE TO CREDIT CARD ERROR

1. BUILDING SOLD OR REMOVED

15. INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

2. CONTENTS SOLD OR REMOVED
3. POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON
EXPIRATION DATE WITH OTHER INSURANCE COVERAGE

16. DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP
18. MORTGAGE PAID OFF ON MPPP POLICY

4. DUPLICATE NFIP POLICIES

19. INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR

5. NON-PAYMENT
6. RISK NOT ELIGIBLE FOR COVERAGE
7.

PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

20. POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE LOSS PROPERTY)
21. OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

8. POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED
BY MORTGAGEE AS PROPERTY NOT IN SFHA

22. CANCEL/REWRITE DUE TO MISRATING

9. INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

24. CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

C
O
P
Y

23. FRAUD (FEMA APPROVAL REQUIRED)

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE OR AT request of insured)

I
N
S
U
R
E
D

Signature

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 INSURED Date (MM / DD / YYYY)
(NOT REQUIRED FOR REASON 5, 6, OR 22)

/

/
/
signature of other insured Date (MM / DD / YYYY)

FEMA Form 086-0-2

/
/
SIGNATURE OF AGENT/Producer Date (MM / DD / YYYY)

Previously FEMA Form 81-17

F-052 (Revised Aug 2010)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT/Producer: 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

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

National Flood Insurance Program

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM

POLICY #:

Policy
Period

Important – Please Print Or Type; Enter Dates as MM/DD/YYYY.

Policy Period is from

/

to

/

/

/

Cancellation Effective Date:

agency no.:

agent’s tax id:

phone no.:

fax no.:

EMAIL ADDRESS:

1sT
mortgagee

NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:

NAME AND MAILING ADDRESS OF INSURED FOR MAILING REFUND:

M
O
R
T
G
A
G
E
E

PHONE NO.:

Property Location

Insured property location:

Loan No.:
2nd mortgageE / 
Other

/

Insured Information

Agent/Producer
Information

NAME AND MAILING ADDRESS OF AGENT/PRODUCER ON THE POLICY BEING CANCELED.

/

NAME AND MAILING ADDRESS OF OTHER PARTIES NOTIFIED:

10. CONDOMINIUM POLICY (UNIT OR ASSOCIATION) CONVERTING TO RCBAP
12. MORTGAGE PAID OFF

CANCELLATION REASON CODE:

REFUND

CanceLlation Reason CODES

13. VOIDANCE PRIOR TO EFFECTIVE DATE
14. VOIDANCE DUE TO CREDIT CARD ERROR

1. BUILDING SOLD OR REMOVED

15. INSURANCE NO LONGER REQUIRED BASED ON FEMA REVIEW OF
LENDER’S SFHA DETERMINATION (LODR)

2. CONTENTS SOLD OR REMOVED
3. POLICY CANCELED AND REWRITTEN TO ESTABLISH COMMON
EXPIRATION DATE WITH OTHER INSURANCE COVERAGE

16. DUPLICATE POLICIES FROM SOURCES OTHER THAN THE NFIP
18. MORTGAGE PAID OFF ON MPPP POLICY

4. DUPLICATE NFIP POLICIES

19. INSURANCE NO LONGER REQUIRED BY MORTGAGEE BECAUSE
STRUCTURE REMOVED FROM SFHA BY MEANS OF LOMA OR LOMR

5. NON-PAYMENT
6. RISK NOT ELIGIBLE FOR COVERAGE
7.

PROPERTY CLOSING DID NOT OCCUR (NO INSURABLE INTEREST)

20. POLICY WRITTEN TO WRONG FACILITY (SEVERE REPETITIVE LOSS PROPERTY)
21. OTHER: CONTINUOUS LAKE FLOODING OR CLOSED BASIN LAKES

8. POLICY OBTAINED FOR PROPERTY CLOSING, BUT NOT REQUIRED
BY MORTGAGEE AS PROPERTY NOT IN SFHA

22. CANCEL/REWRITE DUE TO MISRATING

9. INSURANCE NO LONGER REQUIRED BY MORTGAGEE; PROPERTY NO
LONGER IN SFHA BECAUSE OF PHYSICAL MAP REVISION

24. CANCEL/REWRITE DUE TO MAP REVISION, LOMA, OR LOMR

23. FRAUD (FEMA APPROVAL REQUIRED)

MAKE REFUND PAYABLE TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE ONLY)

MAIL REFUND TO (CHECK ONE):

INSURED

PAYOR

AGENT (REASON 5 ABOVE OR AT request of insured)

C
O
P
Y

Signature

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 INSURED Date (MM / DD / YYYY)
(NOT REQUIRED FOR REASON 5, 6, OR 22)

/

/
/
signature of other insured Date (MM / DD / YYYY)

FEMA Form 086-0-2

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

/
/
SIGNATURE OF AGENT/Producer Date (MM / DD / YYYY)

Previously FEMA Form 81-17

F-052 (Revised Aug 2010)

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SPECIAL NOTE TO INSURANCE AGENT/Producer: SEND ORIGINAL TO NFIP, KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO THE INSURED, AND FOURTH COPY TO MORTGAGEE.

National Flood Insurance Program

Flood Insurance CANCELLATION/NULLIFICATION REQUEST FORM
FEMA FORM 086-0-2
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 7.5 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.