Form 086-0-21 Adjuster Certification Application

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

NATIONAL FLOOD
INSURANCE PROGRAM

ADJUSTER CERTIFICATION APPLICATION

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
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 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.
Recertification

New Certification

Staff Adjuster

Yes

No

Please complete Section I below in its entirety. Then turn the form over and complete all applicable parts in Section II. Sign and date
the form and mail it to: NFIP Bureau & Statistical Agent, Certification Coordinator, P.O. Box 310, Lanham, MD 20703-0310.

SECTION I - PLEASE PRINT
1. NAME

2. FLOOD CERTIFICATION NUMBER (FSN)

3. STREET ADDRESS (include city, state, and zip code)

a. DAYTIME PHONE NO.
b. EVENING PHONE NO.
c. E-MAIL ADDRESS
d. FAX NO.

4. Are you a licensed adjuster?

Yes

No

If yes, which state(s)?

5. Number of years of flood adjuster experience

Number of years of property adjuster experience

6. Has your license ever been revoked?

Yes

No

Yes

No

Yes

No

Yes

No

If yes, reason:

7. Have you ever been suspended or terminated by the NFIP?
If yes, reason:

8. Have you ever attended an NFIP Claims Presentation?
If yes, location:

9. Did you attend a company sponsored training session?

Date Attended:

Company:

If yes, location:
10. Present Errors and Omissions Carrier:

SECTION II - PLEASE PRINT
Check "Yes" or "No" to indicate the category(s) in which you are seeking certification:
11. Residential (Dwelling)

Yes

No

12. Manufactured (Mobile) Home/Travel Trailer

Yes

No

13. Small Commercial (up to $100,00)

Yes

No

14. Large Commercial (from $100,001 to $500,000)

Yes

No

15. Condominium (RCBAP)

Yes

No

Commercial (General Property)

FEMA Form 086-0-21, OCT 07

REPLACES ALL PREVIOUS EDITION.

F-673

SECTION II - (continued)
For the category(ies) that you have selected, answer the following questions:
* What is the building dollar limit estimate that you have prepared in this category?

* What is the dollar limit on contents inventory that you have prepared?

* What is the largest combined loss and claim that you have adjusted?
Building $

Contents $

Total Amount $

If you have adjusted a condominium loss, provide the name, date of loss, location (complete address), and contact individual, along with
telephone number.

If you are applying for Large Commercial or RCABAP authorization, provide the names of three insurance company claims personnel who can be
contacted to reference your adjusting experience and professionalism.
NAME

COMPANY

DATE

NAME

COMPANY

DATE

NAME

COMPANY

DATE

DECLARATION ACKNOWLEDGEMENT.
I declare that I have read the current Standard Flood Insurance policies (the Dwelling Form, the General Property Form, and the Residential
Condominium Building Association Policy) and that all responses on this application are true and accurate.
I acknowledge that misrepresentation of any information provided on this application is grounds for denial of certification, or for suspension or
termination of certification if misrepresentation is discovered after certification has been granted.

Signature

Date

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