Form FEMA Form 086-0-5 FEMA Form 086-0-5 Flood Insurance Preferred Risk 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

PREFERRED RISK POLICY Application, part 1 (of 2)

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

SECOND MORTGAGEE

POLICY PERIOD

FIRST MORTGAGEE

agent’s tax id:
fax no.:

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

name and Mailing Address of first mortgagee:

1ST mortgageE

property location

loan no.:

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

yes
fema

2nd mortgageE/
Other

disaster
assistance
community

Waiting period:  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

phone no.:

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).

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

building

/

insured
Information

agency no.:
EMAIL ADDRESS:

no
fha

other (specify):
case file no.:
Rating map information

NAME AND Mailing ADDRESS OF

2ND MORTGAGEE

LOSS PAYEE

OTHER

IF OTHER, SPECIFY:

loan no.:

CURRENT MAP INFORMATION

NAME OF COUNTY/PARISH:

N
F
I
P

–

Current COMMUNITY No./PANEL No. AND SUFFIX:
–

COMMUNITY No./PANEL No. AND SUFFIX:

Current FIRM zone:

FIRM zone:

Current BFE:

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

contents

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

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

IS BUILDING located on federal land?

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 INSURED’S principal/PRIMARY RESIDENCE?
yes
no
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, is the tenant REQUESTING BUILDING COVERAGE?
yes
no
if yes, see notice below.

IS COVERAGE FOR A CONDO UNIT?
yes
IS CONDO UNIT A TOWNHOUSE/ROWHOUSE?

no
yes

contents located in*:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
Basement/enclosure and above
lowest floor only above
ground level

l owest floor above ground level
and higher
above ground level more than
1 full floor
*if single family, contents are rated
throughout the building.

Yes

No

B) do any of THE FOLLOWING conditions, arising from 1 or more
occurRences in any 10-year period, exist?
• 2 loss payments, each more than $1,000

Yes

No

• 3 or more loss payments, regardless of amount

Yes

No

• 2 Federal disaster relief payments, each more than $1,000

Yes

No

• 3 Federal disaster relief payments, regardless of amount

Yes

No

• 1 flood insurance claim payment and 1 flood disaster relief
payment (including loans and grants), each more than $1,000

Yes

No

no

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

no

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
CHECK ONE OF THE FOLLOWING:

yes

no

C
O
P
Y

with obstruction

/

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

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

Enter selected option froM the premium tables
in the flood insurance manual

Answer the following to determine a building’s eligibility for a prp:
A) is the building located in a special flood hazard area (SFHA)?

yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

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

THE PREFERRED RISK POLICY (PRP) IS ONLY AVAILABLE IF ALL ANSWERS TO QUESTIONS A AND B
ARE NO, EXCEPT FOR BUILDINGS ELIGIBLE UNDER THE PRP ELIGIBILITY EXTENSION, FOR WHICH THE
ANSWER TO QUESTION A MAY BE YES.

BUILDING ELIGIBILITY

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

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

construction
INFORMATION

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

COVERAGE AND PREMIUM

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

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

Renewal

BUILDING AND CONTENTS COVERAGE COMBINATION
BUILDING: $
CONTENTS: $
PREMIUM: $
CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

signature

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)

SIGNATURE OF INSURED (OPTIONAL)

DATE (MM/DD/YYYY)

FEMA Form 086-0-5

Previously FEMA Form 81-67
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-089 (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

PREFERRED RISK POLICY Application, part 1 (of 2)

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

SECOND MORTGAGEE

POLICY PERIOD

FIRST MORTGAGEE

agent’s tax id:
fax no.:

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

name and Mailing Address of first mortgagee:

1ST mortgageE

property location

loan no.:

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

yes
fema

2nd mortgageE/
Other

disaster
assistance
community

Waiting period:  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

phone no.:

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).

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

building

/

insured
Information

agency no.:
EMAIL ADDRESS:

no
fha

other (specify):
case file no.:
Rating map information

NAME AND Mailing ADDRESS OF

2ND MORTGAGEE

LOSS PAYEE

OTHER

IF OTHER, SPECIFY:

A
G
E
N
T

loan no.:

CURRENT MAP INFORMATION

NAME OF COUNTY/PARISH:

–

Current COMMUNITY No./PANEL No. AND SUFFIX:
–

COMMUNITY No./PANEL No. AND SUFFIX:

Current FIRM zone:

FIRM zone:

Current BFE:

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

contents

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

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

IS BUILDING located on federal land?

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 INSURED’S principal/PRIMARY RESIDENCE?
yes
no
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, is the tenant REQUESTING BUILDING COVERAGE?
yes
no
if yes, see notice below.

IS COVERAGE FOR A CONDO UNIT?
yes
IS CONDO UNIT A TOWNHOUSE/ROWHOUSE?

no
yes

contents located in*:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
Basement/enclosure and above
lowest floor only above
ground level

l owest floor above ground level
and higher
above ground level more than
1 full floor
*if single family, contents are rated
throughout the building.

Yes

No

B) do any of THE FOLLOWING conditions, arising from 1 or more
occurRences in any 10-year period, exist?
• 2 loss payments, each more than $1,000

Yes

No

• 3 or more loss payments, regardless of amount

Yes

No

• 2 Federal disaster relief payments, each more than $1,000

Yes

No

• 3 Federal disaster relief payments, regardless of amount

Yes

No

• 1 flood insurance claim payment and 1 flood disaster relief
payment (including loans and grants), each more than $1,000

Yes

No

no

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

no

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
CHECK ONE OF THE FOLLOWING:

yes

no

C
O
P
Y

with obstruction

/

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

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

Enter selected option froM the premium tables
in the flood insurance manual

Answer the following to determine a building’s eligibility for a prp:
A) is the building located in a special flood hazard area (SFHA)?

yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

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

THE PREFERRED RISK POLICY (PRP) IS ONLY AVAILABLE IF ALL ANSWERS TO QUESTIONS A AND B
ARE NO, EXCEPT FOR BUILDINGS ELIGIBLE UNDER THE PRP ELIGIBILITY EXTENSION, FOR WHICH THE
ANSWER TO QUESTION A MAY BE YES.

BUILDING ELIGIBILITY

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

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

construction
INFORMATION

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

COVERAGE AND PREMIUM

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

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

Renewal

BUILDING AND CONTENTS COVERAGE COMBINATION
BUILDING: $
CONTENTS: $
PREMIUM: $
CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

signature

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)

SIGNATURE OF INSURED (OPTIONAL)

DATE (MM/DD/YYYY)

FEMA Form 086-0-5

Previously FEMA Form 81-67
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-089 (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

PREFERRED RISK POLICY Application, part 1 (of 2)

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

SECOND MORTGAGEE

POLICY PERIOD

FIRST MORTGAGEE

agent’s tax id:
fax no.:

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

name and Mailing Address of first mortgagee:

1ST mortgageE

property location

loan no.:

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

yes
fema

2nd mortgageE/
Other

disaster
assistance
community

Waiting period:  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

phone no.:

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).

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

building

/

insured
Information

agency no.:
EMAIL ADDRESS:

no
fha

other (specify):
case file no.:
Rating map information

NAME AND Mailing ADDRESS OF

2ND MORTGAGEE

LOSS PAYEE

OTHER

IF OTHER, SPECIFY:

I
N
S
U
R
E
D

loan no.:

CURRENT MAP INFORMATION

NAME OF COUNTY/PARISH:

–

Current COMMUNITY No./PANEL No. AND SUFFIX:
–

COMMUNITY No./PANEL No. AND SUFFIX:

Current FIRM zone:

FIRM zone:

Current BFE:

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

contents

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

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

IS BUILDING located on federal land?

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 INSURED’S principal/PRIMARY RESIDENCE?
yes
no
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, is the tenant REQUESTING BUILDING COVERAGE?
yes
no
if yes, see notice below.

IS COVERAGE FOR A CONDO UNIT?
yes
IS CONDO UNIT A TOWNHOUSE/ROWHOUSE?

no
yes

contents located in*:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
Basement/enclosure and above
lowest floor only above
ground level

l owest floor above ground level
and higher
above ground level more than
1 full floor
*if single family, contents are rated
throughout the building.

Yes

No

B) do any of THE FOLLOWING conditions, arising from 1 or more
occurRences in any 10-year period, exist?
• 2 loss payments, each more than $1,000

Yes

No

• 3 or more loss payments, regardless of amount

Yes

No

• 2 Federal disaster relief payments, each more than $1,000

Yes

No

• 3 Federal disaster relief payments, regardless of amount

Yes

No

• 1 flood insurance claim payment and 1 flood disaster relief
payment (including loans and grants), each more than $1,000

Yes

No

no

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

no

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
CHECK ONE OF THE FOLLOWING:

yes

no

with obstruction

C
O
P
Y

/

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

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

Enter selected option froM the premium tables
in the flood insurance manual

Answer the following to determine a building’s eligibility for a prp:
A) is the building located in a special flood hazard area (SFHA)?

yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

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

THE PREFERRED RISK POLICY (PRP) IS ONLY AVAILABLE IF ALL ANSWERS TO QUESTIONS A AND B
ARE NO, EXCEPT FOR BUILDINGS ELIGIBLE UNDER THE PRP ELIGIBILITY EXTENSION, FOR WHICH THE
ANSWER TO QUESTION A MAY BE YES.

BUILDING ELIGIBILITY

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

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

construction
INFORMATION

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

COVERAGE AND PREMIUM

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

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

Renewal

BUILDING AND CONTENTS COVERAGE COMBINATION
BUILDING: $
CONTENTS: $
PREMIUM: $
CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

signature

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)

SIGNATURE OF INSURED (OPTIONAL)

DATE (MM/DD/YYYY)

FEMA Form 086-0-5

Previously FEMA Form 81-67
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-089 (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

PREFERRED RISK POLICY Application, part 1 (of 2)

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

SECOND MORTGAGEE

POLICY PERIOD

FIRST MORTGAGEE

agent’s tax id:
fax no.:

Property PURCHASED ON OR AFTER 07/06/2012:

YES

NO

/

/

M
O
R
T
G
A
G
E
E

name and Mailing Address of first mortgagee:

1ST mortgageE

property location

loan no.:

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

yes
fema

2nd mortgageE/
Other

disaster
assistance
community

Waiting period:  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

phone no.:

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).

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

building

/

insured
Information

agency no.:
EMAIL ADDRESS:

no
fha

other (specify):
case file no.:
Rating map information

NAME AND Mailing ADDRESS OF

2ND MORTGAGEE

LOSS PAYEE

OTHER

IF OTHER, SPECIFY:

loan no.:

CURRENT MAP INFORMATION

NAME OF COUNTY/PARISH:

–

Current COMMUNITY No./PANEL No. AND SUFFIX:
–

COMMUNITY No./PANEL No. AND SUFFIX:

Current FIRM zone:

FIRM zone:

Current BFE:

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

contents

/

NAME AND MAILING ADDRESS OF INSURED:

phone no.:

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

IS BUILDING located on federal land?

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 INSURED’S principal/PRIMARY RESIDENCE?
yes
no
IS BUILDING A RENTAL PROPERTY?
yes
no
IS THE INSURED A TENANT?
yes
no
IF YES, is the tenant REQUESTING BUILDING COVERAGE?
yes
no
if yes, see notice below.

IS COVERAGE FOR A CONDO UNIT?
yes
IS CONDO UNIT A TOWNHOUSE/ROWHOUSE?

no
yes

contents located in*:
ENCLOSURE ONLY
(BASEMENT ONLY NOT ELIGIBLE)
Basement/enclosure and above
lowest floor only above
ground level

l owest floor above ground level
and higher
above ground level more than
1 full floor
*if single family, contents are rated
throughout the building.

Yes

No

B) do any of THE FOLLOWING conditions, arising from 1 or more
occurRences in any 10-year period, exist?
• 2 loss payments, each more than $1,000

Yes

No

• 3 or more loss payments, regardless of amount

Yes

No

• 2 Federal disaster relief payments, each more than $1,000

Yes

No

• 3 Federal disaster relief payments, regardless of amount

Yes

No

• 1 flood insurance claim payment and 1 flood disaster relief
payment (including loans and grants), each more than $1,000

Yes

No

no

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

no

IS BUILDING elevated?
If yes, area below is:

yes
no
free of obstruction

CONSTRUCTION DATE:
/
CHECK ONE OF THE FOLLOWING:

yes

no

with obstruction

/

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

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

Enter selected option froM the premium tables
in the flood insurance manual

Answer the following to determine a building’s eligibility for a prp:
A) is the building located in a special flood hazard area (SFHA)?

yes

ESTIMATED BUILDING REPLACEMENT COST
(INCLUDING FOUNDATION): $

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

THE PREFERRED RISK POLICY (PRP) IS ONLY AVAILABLE IF ALL ANSWERS TO QUESTIONS A AND B
ARE NO, EXCEPT FOR BUILDINGS ELIGIBLE UNDER THE PRP ELIGIBILITY EXTENSION, FOR WHICH THE
ANSWER TO QUESTION A MAY BE YES.

BUILDING ELIGIBILITY

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

IF YES, INDICATE THE PROPERTY PURCHASE DATE:

construction
INFORMATION

AGENT/PRODUCER
Information

Name and Mailing Address of Agent/Producer:

COVERAGE AND PREMIUM

BILLING

FOR Renewal, BILL:
LOSS PAYEE

Transfer (NFIP ONLY)

Prior policy #:

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

Renewal

BUILDING AND CONTENTS COVERAGE COMBINATION
BUILDING: $

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

CONTENTS: $
PREMIUM: $
CONTENTS COVERAGE ONLY
AMOUNT: $
PREMIUM: $

signature

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)

SIGNATURE OF INSURED (OPTIONAL)

DATE (MM/DD/YYYY)

FEMA Form 086-0-5

Previously FEMA Form 81-67
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-089 (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

PREFERRED RISK POLICY 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

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

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?

square feet.

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

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?

If yes, check the applicable items:

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

NO

If yes, check the applicable items:

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
YES
NO
equipment?

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

3. Basement/Subgrade Crawlspace

2. Garage

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

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

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
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

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

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:

Fully

YES

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

NO

(excluding doors) to allow the passage of floodwaters through the
YES
NO
enclosed area?

Partially

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

YES

NO

NO

4. Flood Openings
a) Is the enclosed area/crawlspace constructed with openings

3. Area Below the Elevated Floor

YES

If yes, describe:

square feet.

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.

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 086-0-5

Previously FEMA Form 81-67

F-089 (Revised Aug 2010)

National Flood Insurance Program

PREFERRED RISK POLICY APPLICATION
FEMA FORM 086-0-5
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 10 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.