Form 086-0-16 Cause of Loss and Subrogation Report

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

CAUSE OF LOSS AND SUBROGATION REPORT

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

NAME OF INSURED

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

COMPLETE ADDRESS OF PROPERTY DAMAGED

CAUSE OF LOSS (Check the box(es) that apply)
1.

IMPROPER DIVERSION OF WATER

7.

NEGLIGENT MAINTENANCE OF SEWER LINES

2.

IMPROPER BUILDING

8.

FAILURE TO USE PUMPS

3.

IMPROPER GRADING

9.

INADEQUATE PUMPS

4.

DEBRIS ACCUMULATION

10.

EXCESSIVE DAM WATER RELEASE

5.

INADEQUATE SEWER LINES

11.

EXCESSIVE WATER RELEASE (Mechanical)

6.

IGNORING FLOODPLAIN MANAGEMENT (Regulations) 12.

ANY OTHER FACTOR THAT IDENTIFIES A RESPONSIBLE
PARTY OR ACT AS THE CAUSE (Explain; use the space below)

IDENTIFICATION OF RESPONSIBLE PARTY
NAME
COMPLETE ADDRESS

IS THE RESPONSIBLE PARTY INSURED?
YES

NO

(If yes, by whom?)

IDENTIFICATION OF ANY STATUTES OR POLITICAL SUBDIVISION THAT WOULD CONTROL, LIMIT, OR TIME BAR A TORT ACTION
AGAINST THEM (e.g., a local notice of claim against the municipality or county statute that would preclude suit if the notice was not filed on time usually a short period of time for filing is provided).

MAKE IMMEDIATE TELEPHONE CONTACT WITH THE NFIP BUREAU AND STATISTICAL AGENT IF EXPIRATION OF TIME IS IMMINENT.
STATE INVESTIGATION PERFORMED TO DATE

PLEASE ATTACH ANY DIFINITIVE MATERIAL TO THIS REPORT.
WHAT FURTHER INVESTIGATION IS CONTEMPLATED?

HAS INSURED BEEN ADVISED OF SUBROGATION RESPONSIBILITIES?
YES
DOES INSURED HAVE AN ATTORNEY?
YES
FEMA Form 086-0-16, OCT 07

NO
NO

(If yes, by when?)
NAME OF ATTORNEY

REPLACES ALL PREVIOUS EDITION.

F-092

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