National Flood Insurance Program Claims Forms

Forms and Documents

Document Name	Status
Form 086-0-06 National Flood Insurance Program Worksheet - Contents - Personal Property Form	Modified
Form 086-0-21 Adjuster Certification Application Form	Modified
Form 086-0-20 Adjuster Preliminary Damage Assessment Form	Modified
Form 086-0-19 Increased Cost of Compliance (ICC) Adjuster Report Form	Modified
Form 086-0-18 Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued) Form	Modified
Form 086-0-17 Manufactured (Mobile) Home/Travel Trailer Worksheet Form	Modified
Form 086-0-16 Cause of Loss and Subrogation Report Form	Modified
Form 086-0-15 National Flood Insurance Program Narrative Report Form	Modified
Form 086-0-14 National Flood Insurance Program Final Report Form	Modified
Form 086-0-13 National Flood Insurance Program Preliminary Report Form	Modified
Form 086-0-12 Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy Form	Modified
Form 086-0-11 Notice of Loss Form	Modified
Form 086-0-10 Increase of Compliance Proof of Loss Form	Modified
Form 086-0-9 Proof of Loss Form	Modified
Form 086-0-08 Worksheet - Building (Continued) Form	Modified
Form 086-0-07 Worksheet - Building Form	Modified
Supporting_Statement_1660-0005_033014a SB (6).docx Supporting Statement A	2014-03-31
Pub. 30 Day Federal Register Notice 1660-0005.pdf Supplementary Document	2013-11-05
44 CFR 62 20.pdf Supplementary Document	2013-10-23
privacy_pia_fema_nfipits_10122012.pdf Supplementary Document	2013-10-23
SORN FEMA-NFIP 20060602 4-10-09.pdf Supplementary Document	2013-10-23
Pub 60 Day FRN 1660-0005 07302013.pdf Supplementary Document	2013-10-23
National Flood Insurance Reform Act of 1994.pdf Supplementary Document	2010-07-29
42 USC 4001.pdf Supplementary Document	2010-07-29

IC Document Collections

IC ID	Document Title	Status
21044	National Flood Insurance Program Worksheet - Contents - Personal Property Form	Modified
208986	NFIP Claims Appeal	New
180864	Adjuster Certification Application Form	Modified
180862	Adjuster Preliminary Damage Assessment Form	Modified
180861	Increased Cost of Compliance (ICC) Adjuster Report Form	Modified
180859	Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued) Form	Modified
180858	Manufactured (Mobile) Home/Travel Trailer Worksheet Form	Modified
180856	Cause of Loss and Subrogation Report Form	Modified
180855	National Flood Insurance Program Narrative Report Form	Modified
180854	National Flood Insurance Program Final Report Form	Modified
180852	National Flood Insurance Program Preliminary Report Form	Modified
180851	Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy Form	Modified
180849	Notice of Loss Form	Modified
180848	Increase of Compliance Proof of Loss Form	Modified
180847	Proof of Loss Form	Modified
180846	Worksheet - Building (Continued) Form	Modified
180842	Worksheet - Building Form	Modified

ICR Details

OMB Control No: 1660-0005	ICR Reference No: 201310-1660-003
Status: Historical Active	Previous ICR Reference No: 201007-1660-006
Agency/Subagency: DHS/FEMA	Agency Tracking No:
Title: National Flood Insurance Program Claims Forms
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/01/2014
	Date Received in OIRA: 11/07/2013
Terms of Clearance: Submit discontinuation request for ICR 1660-0095 that is now included as part of this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved
Responses	97,242	0	0
Time Burden (Hours)	72,548	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Claims Forms used for the National Flood Insurance Program are used by policyholders and adjusters to collect the information needed to investigate, document, evaluate, and settle claims against National Flood Insurance Program policies for flood damage to their insured property or qualification for benefits under Increased Cost of Compliance coverage.

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Authorizing Statute(s): PL: Pub.L. 103 - 325 555 Name of Law: National Flood Insurance Reform Act
   US Code: 42 USC 4001 Name of Law: The National Flood Insurance Act of 1968
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 45936	07/30/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 66374	11/05/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

IC Title	Form No.	Form Name
Adjuster Certification Application	086-0-21	Adjuster Certification Application
NFIP Claims Appeal
Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy	086-0-12	Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy
Increased Cost of Compliance (ICC) Adjuster Report	086-0-19	Increased Cost of Compliance (ICC) Adjuster Report
Manufactured (Mobile) Home/Travel Trailer Worksheet	086-0-17	Manufactured (Mobile) Home/Travel Trailer Worksheet
National Flood Insurance Program Worksheet - Contents - Personal Property	086-0-06	National Flood Insurance Program Worksheet - Contents - Personal Property
Worksheet - Building	086-0-07	Building - Worksheet
Increase of Compliance Proof of Loss	086-0-10	Increase Of Compliance Proof of Loss
Notice of Loss	086-0-11	Notice of Loss
National Flood Insurance Program Preliminary Report	086-0-13	National Flood Insurance Program Preliminary Report
National Flood Insurance Program Narrative Report	086-0-15	National Flood Insurance Program Narrative Report
National Flood Insurance Program Final Report	086-0-14	National Flood Insurance Program Final Report
Worksheet - Building (Continued)	086-0-08	NFIP Worksheet Building
Cause of Loss and Subrogation Report	086-0-16	Cause of Loss and Subrogation Report
Adjuster Preliminary Damage Assessment	086-0-20	Adjuster Preliminary Damage Assessment
Proof of Loss	086-0-9	Proof of Loss
Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued)	086-0-18	Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued)

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	97,242	0	0	67,758	0	29,484
Annual Time Burden (Hours)	72,548	0	0	51,613	0	20,935
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The following claims forms have a program increase due to respondents leaving the National Flood Insurance Program (NFIP) Write Your Own program and transfering to the NFIP Direct Servicing Agency: FEMA Form 086-0-06 - Increase from 5,460 to 15,503 FEMA Form 086-0-07 - Increase from 9,100 to 24,360 FEMA Form 086-0-08 - Increase from 3,640 to 9,744 FEMA Form 086-0-09 - Increase from 292 to 827 FEMA Form 086-0-10 - Increase from 520 11,821 FEMA Form 086-0-11 - Increase from 254 to 723 FEMA Form 086-0-12 - Increase from 104 to 295 FEMA Form 086-0-13 - Increase from 255 to 723 FEMA Form 086-0-14 - Increase from 255 to 723 FEMA Form 086-0-15 - Increase from 166 to 472 FEMA Form 086-0-16 - Increase from 364 to 1,034 FEMA Form 086-0-17 - Increase from 10 to 295 FEMA Form 086-0-18 - Increase from 52 to 148 FEMA Form 086-0-19 - Increase from 109 to 2,480 FEMA Form 086-0-20 - Increase from 130 to 1,477 There was a program increase of 900 respondents for submission of NFIP claims appeals. It is estimated to take 2 hours to complete a and submit a claims appeals one time annually. The burden is estimated to be, 900 respondents x 1 claim appeal annually x 2 hours = 1800 and burden hours annually.

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Annual Cost to Federal Government: $5,334,150

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/07/2013

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