Form 086-0-19 Increased Cost of Compliance (ICC) Adjuster Report

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

INCREASED COST OF COMPLIANCE (ICC)
ADJUSTERS REPORT

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

NATIONAL FLOOD
INSURANCE PROGRAM
2. NAME OF INSURER

1. NAME OF INSURED
3. PROPERTY ADDRESS (Include city, state, and zip code)

4. COMMUNITY NAME/NUMBER

5. FLOOD ZONE

6. POLICY NUMBER

7. POLICY TERM

8. BUILDING POLICY LIMIT

9. DATE OF LOSS

10. OCCUPANCE TYPE

11. ADJUSTING COMPANY

12. ADJUSTERS FILE NO.

13. Has the Insured received a determination from the community official that the structure must be brought into compliance with the local floodplain
Date of Declaration
management ordiance?
Yes
No
14. Local Official's Name:

15. Telephone Number

16. Under the flood loss meet the NFIP/ICC 50% substantial damage or average 25% repetitive loss requirements?
Yes

No

17. Under which provision is the ICC claim based?

Mitigation option(s):

Substantial Damage

Repetitive Loss

Demolition

Elevation

Floodproofing

Demolition/Elevation or Floodproofing

Relocation/Elevation or Floodproofing

Relocation

18. If relocation, indicate the following:
New address:

New flood risk zone:

19. Current valuation of structure as determined by the community official $
20. Basis of valuation:
21. Full cost of compliance not limited to the amount of ICC coverage

$

22. Amount paid under the ICC Coverage D (excluding salvage and subrogation)

$

If repetitive loss, indicate the following (paid flood building claims only):
Date of Prior Claim
within 10 yrs.

Insurer

Policy Number

Building Payment

RCV Damages
(whole dollars)

ACV Damages
(whole dollars)

23. If repetitive loss, the valuation of the structure as determined by the community official near the date of the prior loss:
$

Date of valuation:

24. Basis of valuation:
25. DATE OF REPORT

FEMA Form 086-0-19, JAN 08

26. ADJUSTERS SIGNATURE

27. ADJUSTER'S FCN

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