Form 086-0-20 Adjuster Preliminary Damage Assessment

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

ADJUSTER PRELIMINARY DAMAGE ASSESSMENT

NATIONAL FLOOD
INSURANCE PROGRAM

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

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
nonduplication of benefits; to the Department of Justice for purposes of litigation or as required by law; and to State and Local agencies for acquisition and relocationrelated 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 this form is estimated to average 15 minutes per response. The burden estimate includes the time, effort or financial resources expended
by persons to generate, maintain, retain, disclose, or provide information to the Mitigation Division or its agent. 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. Send completed forms to: NFIP Bureau & Statistical Agent, Certification Coordinator, P.O. box 310 , Lanham, MD 20703-0310.
WYO COMPANY

DATE OF LOSS

ADJUSTER

FICO NUMBER

This form is to be used for advisory purposes in helping FEMA and communities identify potential substantially damaged buildings. The adjuster will use
"replacement cost" when completing this form; however, the community is required under the National Flood Insurance Program to use "market value" in
determining substantial damage.
PLEASE PRINT LEGIBLY
POLICY HOLDER

POLICY NUMBER

PROPERTY ADDRESS (include zip code)

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE
$

POLICY HOLDER

BUILDING ACTUAL CASH VALUE
$

POLICY NUMBER

PROPERTY ADDRESS (include zip code)

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE
$

POLICY HOLDER

BUILDING ACTUAL CASH VALUE
$

POLICY NUMBER

PROPERTY ADDRESS (include zip code)

**PROBABLE REPAIR COST

BUILDING REPLACEMENT COST VALUE
$

BUILDING ACTUAL CASH VALUE
$

**This is an estimate of the cost to repair the building to its pre-flood condition.
FEMA Form 086-0-20, OCT 07

REPLACES ALL PREVIOUS EDITIONS.

F-674

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