Form 086-0-9 Proof of Loss

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM

POLICY NO. FL

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

PROOF OF LOSS
POLICY TERM

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

AMT OF BLDG COV AT TIME OF LOSS
AGENT
AMT OF CONTS COV AT TIME OF
LOSS

AGENCY AT

TO THE NATION FLOOD INSURANCE PROGRAM:
At time of loss, by above indicated policy of insurance, you insured the interest of

against loss by flood to the property described according to the terms and conditions of said policy and of all forms, endorsements, transfers and assignments attached
thereto.

TIME AND ORIGIN.

A
on the

day of

20

loss occurred about the
. The cause of said loss was: hour of

o'clock

M.,

OCCUPANCY

The premises described, or containing the property described, was occupied at the time of the loss as follows, and for no other purpose
whatever:

INTEREST

No other person or persons had any interest therein or encumberance thereon except

1. FULL AMOUNT OF INSURANCE application to the property for which claim is presented
is...................................$
2. ACTUAL CASH VALUE of building structures............................................................................................$
3. ADD ACTUAL CASH VALUE OF CONTENTS of personal property
insured......................................................$
4. ACTUAL CASH VALUE OF ALL PROPERTY...........................................................................................$
5. FULL COST OF REPAIR OR REPLACEMENT (Building and
Contents)............................................................$
6. LESS APPLICABLE DEPRECIATION......................................................................................................$
7. ACTUAL CASH VALUE LOSS is............................................................................................................$
8. LESS DEDUCTIBLES ..........................................................................................................................$
9. NET AMOUNT CLAIMED under above numbered policy is ...........................................................................
$
The said loss did not originate by any act, design or procurement on the part of your insured, nothing has been done by or with the privity or consent of
insured to violate the conditions of the policy, or render it void; no articles are mentioned herein or in annexed schedules but such as were destroyed or damaged
at the time of said loss, no property saved has in any manner been concealed, and no attempt to deceive the said insurer as to the extent of said loss, has in any
manner been made. Any other information that may be required will be furnished and considered a part of this proof.
I understand that this insurance (policy) is issued Pursuant to the National Flood Insurance Act of 1968, or Any Act Amendatory thereof, and Applicable
Federal Regulations in Title 44 of the Code of Federal Regulations, Subchapter B, and that knowingly and willfully making any false answers or
misrepresentations of fact may be punishable by fine of imprisonment under applicable United State Codes.
Subrogation - To the extent of the payment made or advanced under this policy; the insured hereby assigns, transfers and sets over the insurer all rights,
claims or interest that he has against any person, firm or corporation liable for the loss or damage to the property for which payment is made or advanced. He also
hereby authorizes the insurer to sue any such third party in his name.
The insured hereby warrants that no release has been given or will be given or settlement or compromise made or agreed upon with any third party who
may be liable in damages to the insured with respect to the claim being made herein.
The furnishing of this blank or the preparation of proofs by a representative of the above insurer is not a waiver of any of its rights.
I declare under penalty of perjury that the information contained in the foregoing is true and correct to the best of my knowledge and belief.

Executed this

day of

, 20

Name

FEMA Form 086-0-9 , OCT 07

REPLACES ALL PREVIOUS EDITIONS.

F-101

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 (Continued)
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