Form 086-0-17 Manufactured (Mobile) Home/Travel Trailer Worksheet

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

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

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

MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER WORKSHEET

Insured:

Policy No.:

Location of Risk:

Date of Loss

Year

Manufacturer

Model

Size

Serial Number

Color

No. of Bedrooms

Date of Purchase

New Or Used

Was Land Included
No
Yes

Furniture included
Yes
No

Cost

Type Of Foundation

Number Of Axels

Type Of Tie Down

Are Wheels on unit
Yes
No

Repairs Agreed
Yes
No

R/C Repair Amount

Salvage Value

Salvor Name

Building Coverage

Content Coverage

Does It Cover Flood?
Yes
No

Other Insurance Carrier:
Policy Number

Value New

Addn/Options R/C

Total R/C

Depreciation

Depreciation

Depreciation

Value Used

Addn/Options A/C

Total ACV

Dwelling Form - Section VII, V., 3., Special Loss Settlement applies to a single family dwelling that is a
manufactured or mobile home or travel trailer, which is at least 16 feet wide and has an area of at least 600 square feet
within its perimeter walls, which is owner occupied, on a principal basis, and insured to value.
Special Loss Calculation
Mobile Home Used Book Value

$

x 1.5 =

Replacement Cost Value of Actions, and or Options

+

Maximum Amount Payable

$

(Draw building diagram and dimensions of rooms below, and indicate location of tie downs)

Adjuster:

FEMA Form 086-0-17, JAN 08

Examiner:

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