Form 086-0-13 National Flood Insurance Program Preliminary Report

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

O.M.B. No. 1660-0005
Expires September 30, 2010
See Reverse side for Privacy Act Statement and
Paperwork Burden Disclosure Notice

THE NFIP REQUIRES THAT A PRELIMINARY REPORT BE RECEIVED WITHIN 15 DAYS OF ASSIGNMENT,
AND AN INTERIM OR FINAL REPORT NOT LATER THAN EVERY 30 DAYS THEREAFTER.

PRELIMINARY REPORT

INSURED

POLICY NUMBER

PROPERTY ADDRESS

DATE OF LOSS

MAILING ADRESS

CATASTROPHE NO.

INSURED TELEPHONE NUMBER: HOME

WORK

ADJ. FILE NO.

ADJUSTING COMPANY

TAX ID NUMBER

ADJUSTER ADDRESS

ADJ. PHONE NO.

DATE LOSS ASSIGNED
E Building worksheets
N
C Contents worksheets
L.

DATE INSURED CONTACTED
(

)

Photographs

)

Narrative

(

(

)
pp)

Agent's Daily

NFIP

Coverage verified from:

(

I
Term
to
N
S
U
R
A
N
C
E ADVANCE PAYMENT REQUESTED?

DATE LOSS INSPECTED
Proof of Loss

Other

R/C Proof

Other

Insured's Policy

Dwelling

No

Building

Yes:

Regular

General Property

RCBAP

Deductible

Coverage
RESERVES:

Emergency

Program:

Reserve

$

$

$

$

$

$
Contents

$

$

If yes, Proof of Loss for amount of payment and supporting documentation must be submitted with this report.
Single Family

Type of Building:

2-4 Family

Mobile Home/Travel Trailer:
Occupancy:
Title Verified?

Condo Association

Condo Unit

Make:

Model:

Owner

Tenant

State government owned

Yes

No

Source of verification:

Number of floors in building including basement:

1

In case of multiple occupancy, indicate floor(s) occupied by insured:
Type of basement:

Unfinished

None

R Building elevated?
I Is risk under construction?
S
K FIRM Date

No

Pre Firm

Basement

Brick or stone

Breakway walls

Yes

No

Good
Good

Unreinf. block

Brick

Other

Reinf. block

Block

Reinf. concrete shear

Contents located in:

Finished

Fair
Fair

Reinf. concrete

Wood stud

No

Unfinished

Poor
Poor

Contents:

Treated plywood

Brick

Very Good
Very Good
Other

Exterior wall surface treatment:

Stone/brick veneer
Unfinished
Wood siding
Metal sheathing/siding
Vinly sheathing/siding
Other
First floor
Basement
Basement and first floor
First floor and above
Second floor and above
Stucco

Nearest body of water:
Cause of loss:

Seasonal

Second and or/above

Building:

Other

Other than household

Principal

Yes

Post Firm

Concrete
Wood
Steel
Piers:
Reinf. concrete
Walls:
Wood post
Other
Concrete slab
Exterior wall structure:
Reinf. concrete
Concrete bock

Household

First

Finished

Piles:

Steel and glass

Residency:

Is building a split level?

Foundation area enclosure?
None
New building
Improvement in progress

Yes
No

Non- Residential

Serial Number:

Unoccupied

3 or more

2

Other Residential

Distance from risk:
Tidal water overflow

No: Explain fully under remarks
Stream, river, or lake overflow
Alluvial fan overflow

Yes: Indicate cause of loss
Accumulation of rainfall or snowmelt

Low velocity flow or ponding
Wave action
Mudflow
Erosion
Velocity flow
O
R
Yes
No
I
G Did other than natural cause contribute to flooding?
If "yes" to either question, complete "Cause of Loss and Subrogation Report"
Yes
No
I
Water Height or Wave Action:
N Date/time water entered building:
Date/time water receded building:
Date of Report
FEMA Form 086-0-13, OCT 07

Length of time water remained in building:
Adjuster's Signature
REPLACES ALL PREVIOUS EDITIONS

Apt. Building/condo Unit:
Adjuster's FC Number

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