Form FEMA Form 086-0-3 FEMA Form 086-0-3 Flood Insurance General Change Endorsement

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 General Change Endorsement, part 1 (of 2)

POLICY #:

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

MAILING ADDRESS
BILLING
AGENT/PRODUCER

NEW PURCHASE
DATE OF PURCHASE:
/
/

FOR Renewal, BILL:

/

/

phone no.:

agent’s tax id:
fax no.:

Elevation
Data

loan no.:

BUILDING OCCUPANCY
SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)
BUILDING PURPOSE
100% RESIDENTIAL
100% NON-RESIDENTIAL
MIXED-USE — SPECIFY
PERCENTAGE OF RESIDENTIAL
USE:
%
IS BUILDING A BUSINESS
PROPERTY?
yes
no

NAME AND Mailing ADDRESS OF:

2nd mortgageE/
other

name and Mailing Address of first mortgagee:

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:

EMERGENCY

loan no.:

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

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

1
2
3 or more
split level
Townhouse/rowhouse (rcbap low-rise only)
manufactured (mobile) home/travel trailer on foundation
Is coverage for a condo unit?
yes
nO
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
TOTAL NUMBER OF UNITS:
HIGH-RISE
LOW-RISE

yes

If no, describe:
*if single family, contents are rated
throughout the building.

Building Diagram No.:

IS BUILDING elevated?
If yes, area below is:

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

lowest adjacent grade (LAG):

LOWEST FLOOR ELEVATION:

yes
no
free of obstruction

(–) BASE FLOOD ELEVATION:
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
/

Elevation certification date:
yes

n
f
i
p

c
o
p
y

/
(+ OR –)

no

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

DEDUCTIBLE*:
BUILDING $
Deductible Buyback?
yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

no

yes

(=) DIFFERENCE TO NEAREST FOOT:

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

no

yes

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

nO

is personal property household
contents?
yes
no

yes

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.

Number of floors in building (includING basement/enclosed
area, if any) or building type

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no
(IF POST-FIRM CONSTRUCTION IN ZONES A, A1–A30, AE,
AO, AH, V, V1–V30, VE, OR IF PRE-FIRM CONSTRUCTION
IS ELEVATION RATED, attach Elevation Certificate.)

LOSS PAYEE

GRANDFATHERING information
yes
no
If yes, Built in compliance or
Grandfathered?
Continuous coverage Prior policy no.:
–
Current COMMUNITY No./PANEL No. AND SUFFIX:
Current FIRM zone:
Current BFE:

–

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

other (specify):

construction
information

contents

building

community

1st MORTGAGEE

EMAIL ADDRESS:

Rating map information
NAME OF COUNTY/PARISH:
COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

note: one building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED 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).

Property location

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

agency no.:

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

NAME AND MAILING ADDRESS OF INSURED:

for added coverage, indicate the APPLICABLE waiting period:
standard 30-day
Required for loan transaction — no waiting
map revision (zone change from non-sFHa to sFHa) — 1 Day

phone no.:

LOSS PAYEE

FIRST MORTGAGEE
SECOND MORTGAGEE

Other (specify):

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

INSURED

insured
Information

Assignment

Change
policy
period

MORTGAGEE
INCREASE COVERAGE
BUILDING INFORMATION
insured information
OTHER (specify):

BILLING

reason for Assignment:

reason for change (CHECK ALL THAT APPLY)

CONTENTS $
no

* The PRP PROVIDES THE STANDARD DEDUCTIBLEs ONLY.

coverage and rating

to increase/decrease coverage, complete sections a & b. For rate change, complete section a only.
Section a – current Limits
insurance coverage

rate

premium

amount

rate

premium

BUILDING

CONTENTS

PREMIUM

BUILDING

CONTENTS

PREMIUM

A+B
premium

building basic Limit
building additional Limit
contents basic Limit
contents additional Limit
FOR PRP ONLY, ENTER LIMITS FROM THE
NFIP FLOOD INSURANCE MANUAL

if changing amount of insurance, enter new total amount below
building coverage
basic

additional

if return premium, mail refund to:

signature

Section b – NEW Limits

amount

payment method:

contents coverage
total

insured

basic

additional

agent/producer

check
credit card
other:

total

DEDUCTIBLE discount/surcharge
subtotal
icc premium
subtotal

payor

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.

CRS PREMIUM DISCOUNT

%

subtotal
RESERVE FUND

%

SUBTOTAL

/

/

premium previously paid (Excludes
Probation Surcharge/Federal Policy Fee)

/

/

difference

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

/

SIGNATURE OF ASSIGNEE (FOR ASSIGNMENT ONLY) DATE (MM/DD/YYYY)

FEMA Form 086-0-3

subtotal

(+/–)

pro-rata factor
/

Previously FEMA Form 81-18

total Amount Due

(+/–)

F-051 (Revised Aug 2010)

PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS ENDORSEMENT. IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK OR MONEY ORDER TO ORIGINAL AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO 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 General Change Endorsement, part 1 (of 2)

POLICY #:

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

MAILING ADDRESS
BILLING
AGENT/PRODUCER

NEW PURCHASE
DATE OF PURCHASE:
/
/

FOR Renewal, BILL:

/

/

phone no.:

agent’s tax id:
fax no.:

Elevation
Data

loan no.:

BUILDING OCCUPANCY
SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)
BUILDING PURPOSE
100% RESIDENTIAL
100% NON-RESIDENTIAL
MIXED-USE — SPECIFY
PERCENTAGE OF RESIDENTIAL
USE:
%
IS BUILDING A BUSINESS
PROPERTY?
yes
no

NAME AND Mailing ADDRESS OF:

2nd mortgageE/
other

name and Mailing Address of first mortgagee:

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:

EMERGENCY

loan no.:

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

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

1
2
3 or more
split level
Townhouse/rowhouse (rcbap low-rise only)
manufactured (mobile) home/travel trailer on foundation
Is coverage for a condo unit?
yes
nO
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
TOTAL NUMBER OF UNITS:
HIGH-RISE
LOW-RISE

yes

If no, describe:
*if single family, contents are rated
throughout the building.

Building Diagram No.:

IS BUILDING elevated?
If yes, area below is:

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

lowest adjacent grade (LAG):

LOWEST FLOOR ELEVATION:

yes
no
free of obstruction

(–) BASE FLOOD ELEVATION:
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
/

Elevation certification date:
yes

A
G
E
N
T
C
O
P
Y

/
(+ OR –)

no

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

DEDUCTIBLE*:
BUILDING $
Deductible Buyback?
yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

no

yes

(=) DIFFERENCE TO NEAREST FOOT:

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

no

yes

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

nO

is personal property household
contents?
yes
no

yes

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.

Number of floors in building (includING basement/enclosed
area, if any) or building type

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no
(IF POST-FIRM CONSTRUCTION IN ZONES A, A1–A30, AE,
AO, AH, V, V1–V30, VE, OR IF PRE-FIRM CONSTRUCTION
IS ELEVATION RATED, attach Elevation Certificate.)

LOSS PAYEE

GRANDFATHERING information
yes
no
If yes, Built in compliance or
Grandfathered?
Continuous coverage Prior policy no.:
–
Current COMMUNITY No./PANEL No. AND SUFFIX:
Current FIRM zone:
Current BFE:

–

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

other (specify):

construction
information

contents

building

community

1st MORTGAGEE

EMAIL ADDRESS:

Rating map information
NAME OF COUNTY/PARISH:
COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

note: one building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED 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).

Property location

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

agency no.:

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

NAME AND MAILING ADDRESS OF INSURED:

for added coverage, indicate the APPLICABLE waiting period:
standard 30-day
Required for loan transaction — no waiting
map revision (zone change from non-sFHa to sFHa) — 1 Day

phone no.:

LOSS PAYEE

FIRST MORTGAGEE
SECOND MORTGAGEE

Other (specify):

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

INSURED

insured
Information

Assignment

Change
policy
period

MORTGAGEE
INCREASE COVERAGE
BUILDING INFORMATION
insured information
OTHER (specify):

BILLING

reason for Assignment:

reason for change (CHECK ALL THAT APPLY)

CONTENTS $
no

* The PRP PROVIDES THE STANDARD DEDUCTIBLEs ONLY.

coverage and rating

to increase/decrease coverage, complete sections a & b. For rate change, complete section a only.
Section a – current Limits
insurance coverage

rate

premium

amount

rate

premium

BUILDING

CONTENTS

PREMIUM

BUILDING

CONTENTS

PREMIUM

A+B
premium

building basic Limit
building additional Limit
contents basic Limit
contents additional Limit
FOR PRP ONLY, ENTER LIMITS FROM THE
NFIP FLOOD INSURANCE MANUAL

if changing amount of insurance, enter new total amount below
building coverage
basic

additional

if return premium, mail refund to:

signature

Section b – NEW Limits

amount

payment method:

contents coverage
total

insured

basic

additional

agent/producer

check
credit card
other:

total

DEDUCTIBLE discount/surcharge
subtotal
icc premium
subtotal

payor

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.

CRS PREMIUM DISCOUNT

%

subtotal
RESERVE FUND

%

SUBTOTAL

/

/

premium previously paid (Excludes
Probation Surcharge/Federal Policy Fee)

/

/

difference

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

/

SIGNATURE OF ASSIGNEE (FOR ASSIGNMENT ONLY) DATE (MM/DD/YYYY)

FEMA Form 086-0-3

subtotal

(+/–)

pro-rata factor
/

Previously FEMA Form 81-18

total Amount Due

(+/–)

F-051 (Revised Aug 2010)

PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS ENDORSEMENT. IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK OR MONEY ORDER TO ORIGINAL AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO 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 General Change Endorsement, part 1 (of 2)

POLICY #:

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

MAILING ADDRESS
BILLING
AGENT/PRODUCER

NEW PURCHASE
DATE OF PURCHASE:
/
/

FOR Renewal, BILL:

/

/

phone no.:

agent’s tax id:
fax no.:

Elevation
Data

loan no.:

BUILDING OCCUPANCY
SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)
BUILDING PURPOSE
100% RESIDENTIAL
100% NON-RESIDENTIAL
MIXED-USE — SPECIFY
PERCENTAGE OF RESIDENTIAL
USE:
%
IS BUILDING A BUSINESS
PROPERTY?
yes
no

NAME AND Mailing ADDRESS OF:

2nd mortgageE/
other

name and Mailing Address of first mortgagee:

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:

EMERGENCY

loan no.:

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

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

1
2
3 or more
split level
Townhouse/rowhouse (rcbap low-rise only)
manufactured (mobile) home/travel trailer on foundation
Is coverage for a condo unit?
yes
nO
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
TOTAL NUMBER OF UNITS:
HIGH-RISE
LOW-RISE

yes

If no, describe:
*if single family, contents are rated
throughout the building.

Building Diagram No.:

IS BUILDING elevated?
If yes, area below is:

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

lowest adjacent grade (LAG):

LOWEST FLOOR ELEVATION:

yes
no
free of obstruction

(–) BASE FLOOD ELEVATION:
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
/

Elevation certification date:
yes

I
N
S
U
R
E
D
C
O
P
Y

/
(+ OR –)

no

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

DEDUCTIBLE*:
BUILDING $
Deductible Buyback?
yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

no

yes

(=) DIFFERENCE TO NEAREST FOOT:

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

no

yes

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

nO

is personal property household
contents?
yes
no

yes

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.

Number of floors in building (includING basement/enclosed
area, if any) or building type

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no
(IF POST-FIRM CONSTRUCTION IN ZONES A, A1–A30, AE,
AO, AH, V, V1–V30, VE, OR IF PRE-FIRM CONSTRUCTION
IS ELEVATION RATED, attach Elevation Certificate.)

LOSS PAYEE

GRANDFATHERING information
yes
no
If yes, Built in compliance or
Grandfathered?
Continuous coverage Prior policy no.:
–
Current COMMUNITY No./PANEL No. AND SUFFIX:
Current FIRM zone:
Current BFE:

–

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

other (specify):

construction
information

contents

building

community

1st MORTGAGEE

EMAIL ADDRESS:

Rating map information
NAME OF COUNTY/PARISH:
COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

note: one building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED 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).

Property location

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

agency no.:

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

NAME AND MAILING ADDRESS OF INSURED:

for added coverage, indicate the APPLICABLE waiting period:
standard 30-day
Required for loan transaction — no waiting
map revision (zone change from non-sFHa to sFHa) — 1 Day

phone no.:

LOSS PAYEE

FIRST MORTGAGEE
SECOND MORTGAGEE

Other (specify):

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

INSURED

insured
Information

Assignment

Change
policy
period

MORTGAGEE
INCREASE COVERAGE
BUILDING INFORMATION
insured information
OTHER (specify):

BILLING

reason for Assignment:

reason for change (CHECK ALL THAT APPLY)

CONTENTS $
no

* The PRP PROVIDES THE STANDARD DEDUCTIBLEs ONLY.

coverage and rating

to increase/decrease coverage, complete sections a & b. For rate change, complete section a only.
Section a – current Limits
insurance coverage

rate

premium

amount

rate

premium

BUILDING

CONTENTS

PREMIUM

BUILDING

CONTENTS

PREMIUM

A+B
premium

building basic Limit
building additional Limit
contents basic Limit
contents additional Limit
FOR PRP ONLY, ENTER LIMITS FROM THE
NFIP FLOOD INSURANCE MANUAL

if changing amount of insurance, enter new total amount below
building coverage
basic

additional

if return premium, mail refund to:

signature

Section b – NEW Limits

amount

payment method:

contents coverage
total

insured

basic

additional

agent/producer

check
credit card
other:

total

DEDUCTIBLE discount/surcharge
subtotal
icc premium
subtotal

payor

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.

CRS PREMIUM DISCOUNT

%

subtotal
RESERVE FUND

%

SUBTOTAL

/

/

premium previously paid (Excludes
Probation Surcharge/Federal Policy Fee)

/

/

difference

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

/

SIGNATURE OF ASSIGNEE (FOR ASSIGNMENT ONLY) DATE (MM/DD/YYYY)

FEMA Form 086-0-3

subtotal

(+/–)

pro-rata factor
/

Previously FEMA Form 81-18

total Amount Due

(+/–)

F-051 (Revised Aug 2010)

PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS ENDORSEMENT. IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK OR MONEY ORDER TO ORIGINAL AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO 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 General Change Endorsement, part 1 (of 2)

POLICY #:

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

MAILING ADDRESS
BILLING
AGENT/PRODUCER

NEW PURCHASE
DATE OF PURCHASE:
/
/

FOR Renewal, BILL:

/

/

phone no.:

agent’s tax id:
fax no.:

Elevation
Data

loan no.:

BUILDING OCCUPANCY
SINGLE FAMILY
2–4 FAMILY
OTHER RESIDENTIAL
NON-RESIDENTIAL
(INCLUDING HOTEL/MOTEL)
BUILDING PURPOSE
100% RESIDENTIAL
100% NON-RESIDENTIAL
MIXED-USE — SPECIFY
PERCENTAGE OF RESIDENTIAL
USE:
%
IS BUILDING A BUSINESS
PROPERTY?
yes
no

NAME AND Mailing ADDRESS OF:

2nd mortgageE/
other

name and Mailing Address of first mortgagee:

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
EXTENSIONS, DESCRIBE the INSURED BUILDING:

EMERGENCY

loan no.:

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

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

1
2
3 or more
split level
Townhouse/rowhouse (rcbap low-rise only)
manufactured (mobile) home/travel trailer on foundation
Is coverage for a condo unit?
yes
nO
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
TOTAL NUMBER OF UNITS:
HIGH-RISE
LOW-RISE

yes

If no, describe:
*if single family, contents are rated
throughout the building.

Building Diagram No.:

IS BUILDING elevated?
If yes, area below is:

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

lowest adjacent grade (LAG):

LOWEST FLOOR ELEVATION:

yes
no
free of obstruction

(–) BASE FLOOD ELEVATION:
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
/

Elevation certification date:
yes

/
(+ OR –)

no

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

DEDUCTIBLE*:
BUILDING $
Deductible Buyback?
yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

no

yes

(=) DIFFERENCE TO NEAREST FOOT:

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

no

yes

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

nO

is personal property household
contents?
yes
no

yes

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.

Number of floors in building (includING basement/enclosed
area, if any) or building type

IS BUILDING POST-FIRM CONSTRUCTION?
yes
no
(IF POST-FIRM CONSTRUCTION IN ZONES A, A1–A30, AE,
AO, AH, V, V1–V30, VE, OR IF PRE-FIRM CONSTRUCTION
IS ELEVATION RATED, attach Elevation Certificate.)

LOSS PAYEE

GRANDFATHERING information
yes
no
If yes, Built in compliance or
Grandfathered?
Continuous coverage Prior policy no.:
–
Current COMMUNITY No./PANEL No. AND SUFFIX:
Current FIRM zone:
Current BFE:

–

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

other (specify):

construction
information

contents

building

community

1st MORTGAGEE

EMAIL ADDRESS:

Rating map information
NAME OF COUNTY/PARISH:
COMMUNITY No./PANEL No. AND SUFFIX:
FIRM zone:
COMMUNITY PROGRAm TYPE IS:
REGULAR

note: one building per policy — blanket coverage not permitted.
IS INSURED PROPERTY LOCATION SAME AS INSURED 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).

Property location

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

agency no.:

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

NAME AND MAILING ADDRESS OF INSURED:

for added coverage, indicate the APPLICABLE waiting period:
standard 30-day
Required for loan transaction — no waiting
map revision (zone change from non-sFHa to sFHa) — 1 Day

phone no.:

LOSS PAYEE

FIRST MORTGAGEE
SECOND MORTGAGEE

Other (specify):

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

INSURED

insured
Information

Assignment

Change
policy
period

MORTGAGEE
INCREASE COVERAGE
BUILDING INFORMATION
insured information
OTHER (specify):

BILLING

reason for Assignment:

reason for change (CHECK ALL THAT APPLY)

CONTENTS $
no

coverage and rating

Section a – current Limits
rate

premium

amount

rate

premium

BUILDING

CONTENTS

PREMIUM

BUILDING

CONTENTS

PREMIUM

A+B
premium

building additional Limit
contents basic Limit
contents additional Limit

if changing amount of insurance, enter new total amount below
building coverage
basic

additional

if return premium, mail refund to:

signature

Section b – NEW Limits

amount

building basic Limit

FOR PRP ONLY, ENTER LIMITS FROM THE
NFIP FLOOD INSURANCE MANUAL

payment method:

contents coverage
total

insured

basic

additional

agent/producer

check
credit card
other:

total

C
O
P
Y

subtotal
DEDUCTIBLE discount/surcharge
subtotal
icc premium
subtotal

payor

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.

CRS PREMIUM DISCOUNT

%

subtotal
RESERVE FUND

%

SUBTOTAL

/

/

premium previously paid (Excludes
Probation Surcharge/Federal Policy Fee)

/

/

difference

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

/

SIGNATURE OF ASSIGNEE (FOR ASSIGNMENT ONLY) DATE (MM/DD/YYYY)

FEMA Form 086-0-3

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

* The PRP PROVIDES THE STANDARD DEDUCTIBLEs ONLY.

to increase/decrease coverage, complete sections a & b. For rate change, complete section a only.
insurance coverage

M
O
R
T
G
A
G
E
E

(+/–)

pro-rata factor
/

Previously FEMA Form 81-18

total Amount Due

(+/–)

F-051 (Revised Aug 2010)

PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS ENDORSEMENT. IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
ATTACH CHECK OR MONEY ORDER TO ORIGINAL AND SEND TO NFIP. KEEP SECOND COPY FOR YOUR RECORDS, GIVE THIRD COPY TO INSURED, AND FOURTH COPY TO MORTGAGEE.

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

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

Flood Insurance General Change
Endorsement, part 2 (of 2)

National Flood Insurance Program
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.

POLICY #:

SECTION­­I – 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

 uilding excluding addition(s) and extension(s)
B
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 2a is YES, answer 2b through 2f.

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

 ddition or extension only (include description in the Property Location
A
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
Solid 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:

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

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.)

2. Anchoring

1. Manufactured (Mobile) Home/Travel Trailer Data

Year of manufacture:

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

Model number:

Serial number:

Make:

Dimensions:

×

If yes, the dimensions are:

×

Ground anchors
Slab anchors
Other (describe):

3. Installation

feet

Are there any permanent additions and/or extensions?

Over-the-top ties
Frame ties
Frame connectors

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 086-0-3

Previously FEMA Form 81-18

F-051 (Revised Aug 2010)

National Flood Insurance Program

Flood Insurance general change endorsement
FEMA Form 086-0-3
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 9 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.