Form 086-0-06 National Flood Insurance Program Worksheet - Contents -

National Flood Insurance
Program

(See Privacy Act Statement
and Paperwork Burden
Disclosure Notice on reverse)

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

WORKSHEET - CONTENTS - PERSONAL
PROPERTY

O.M.B. No. 1660-0005
Expires September 30, 2010

DATE OF REPORT
INSURED AND LOCATION

POLICY NO. FL

(ADJUSTER)

ADJUSTING FIRM AND ADDRESS

1
Item

FEMA Form 086-0-6, OCT 07

Adjuster's File
No.

Date of Loss

2

3

4

5

6

7

8

9

Description

Quantity

Age

Replacement
Cost

Loss or
Damage

Depreciation

A.C.V.
Flood Loss

A.C.V.
Wind Loss

REPLACES ALL PREVIOUS EDITIONS.

Privacy Act Statement
The information requested is necessary to process the subject loss. The authority to collect the information is Title 42, U.S. Code, Section 4001 to
4028. It is voluntary on your part to furnish the information. However, omission of an item may preclude processing of the form. The information
will not be disclosed outside of the Federal Emergency Management Agency, except to the servicing agent, acting as the government's fiscal agent;
to claims adjusters to enable them to confirm coverage and the location of insured property; to certain Federal, State, and Local Government
agencies for determining eligibility for benefits and for verification of agencies for acquisition and relocation-related projects, consistent with the
National Flood Insurance Program and consistent with the routine uses described in the program's system of record. Failure by you to provide some
or all of the information may result in delay in processing or denial of this claim and/or application.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for the collection of information titled Claims for National Flood Insurance Program (NFIP) is estimated to average 6 hours
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 these forms. You are not required to respond to this collection of information unless a currently valid OMB
control number and expiration date is displayed in the upper right corner of the these forms. Send comments regarding the accuracy of the burden
estimate and suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency
Management Agency, 500 C Street, S.W., Washington, DC 20472, Paperwork Reduction Project (1660-0005). NOTE: Do not send your
completed form to this address.
FEMA Form No.
086-0-6
086-0-7
086-0-8
086-0-9
086-0-10
086-0-11
086-0-12
086-0-13
086-0-14
086-0-15
086-0-16
086-0-17
086-0-18
086-0-19
086-0-20
086-0-21

Title
Worksheet-Contents-Personal Property
Worksheet-Building
Worksheet-Building (Cont'd)
Proof of Loss
Increased Cost of Compliance
Notice of Loss
Statement as to Full Cost to Repair or Replacement
Cost Coverage, Subject to the Terms and Conditions
of this Policy
National Flood Insurance Program Preliminary Report
National Flood Insurance Program Final Report
National Flood Insurance Program Narrative Report
Cause of Loss and Subrogation Report
Manufactured (Mobile) Home/Travel Trailer Worksheet
Mobile Home/Travel Trailer Worksheet (Continued)
Increased Cost of Compliance (ICC) Adjuster Report
Adjuster Preliminary Damage Assessment
Adjuster Certification Application

Burden Hours
2.5 Hours
2.5 Hours
1.0 Hours
.08 Hours
2.0 Hours
.07 Hours
.10 Hours
.07 Hours
.07 Hours
.08 Hours
1 Hour
.50 Hours
.25 Hours
.42 Hours
.25 Hours
.25 Hours