National Flood Insurance Program Claims Forms

Forms and Documents

Document Name	Status
Form 086-0-06 National Flood Insurance Program Worksheet - Contents - Personal Property Form	Modified
Form 086-0-21 Adjuster Certification Application Form	Modified
Form 086-0-20 Adjuster Preliminary Damage Assessment Form	Modified
Form 086-0-19 Increased Cost of Compliance (ICC) Adjuster Report Form	Modified
Form 086-0-18 Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued) Form	Modified
Form 086-0-17 Manufactured (Mobile) Home/Travel Trailer Worksheet Form	Modified
Form 086-0-16 Cause of Loss and Subrogation Report Form	Modified
Form 086-0-15 National Flood Insurance Program Narrative Report Form	Modified
Form 086-0-14 National Flood Insurance Program Final Report Form	Modified
Form 086-0-13 National Flood Insurance Program Preliminary Report Form	Modified
Form 086-0-12 Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy Form	Removed
Form 086-0-11 Notice of Loss Form	Modified
Form 086-0-10 Increase of Compliance Proof of Loss Form	Modified
Form 086-0-9 Proof of Loss Form	Modified
Form 086-0-08 Worksheet - Building (Continued) Form	Modified
Form 086-0-07 Worksheet - Building Form	Modified
Supporting Statement 1660-0005 FINAL 7-26-2017.docx Supporting Statement A	2017-07-26
The National Flood Insurance Act of 1968.pdf Supplementary Document	2017-04-27
National Flood Insurance Reform Act of 1994.pdf Supplementary Document	2017-04-27
Published 60 Day FRN 1660-0005.pdf Supplementary Document	2017-04-27
Published 30 Day FRN 1660-0005.pdf Supplementary Document	2017-04-27
108th Congress Public Law 108-264.pdf Supplementary Document	2017-04-12
Narrative of Changes Table (1660-0005 - POL 20161112).docx Supplementary Document	2017-04-12
PTA, FEMA - National Flood Insurance Program (NFIP) Claims and Claim App....pdf Supplementary Document	2017-04-12
42 USC 4102a.pdf Supplementary Document	2017-04-12
Public Law 93-234.pdf Supplementary Document	2017-04-12
Public Law 90-448.pdf Supplementary Document	2017-04-12
44 CFR 62 20.pdf Supplementary Document	2013-10-23
privacy_pia_fema_nfipits_10122012_0.pdf Supplementary Document	2017-04-12
SORN DHS-2014-0028-0001.pdf Supplementary Document	2017-04-12
42 USC 4001.pdf Supplementary Document	2010-07-29

IC Document Collections

IC ID	Document Title	Status
21044	National Flood Insurance Program Worksheet - Contents - Personal Property Form	Modified
208986	NFIP Claims Appeal Other-Manual	Modified
180864	Adjuster Certification Application Form	Modified
180862	Adjuster Preliminary Damage Assessment Form	Modified
180861	Increased Cost of Compliance (ICC) Adjuster Report Form	Modified
180859	Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued) Form	Modified
180858	Manufactured (Mobile) Home/Travel Trailer Worksheet Form	Modified
180856	Cause of Loss and Subrogation Report Form	Modified
180855	National Flood Insurance Program Narrative Report Form	Modified
180854	National Flood Insurance Program Final Report Form	Modified
180852	National Flood Insurance Program Preliminary Report Form	Modified
180851	Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy Form	Removed
180849	Notice of Loss Form	Modified
180848	Increase of Compliance Proof of Loss Form	Modified
180847	Proof of Loss Form	Modified
180846	Worksheet - Building (Continued) Form	Modified
180842	Worksheet - Building Form	Modified

ICR Details

OMB Control No: 1660-0005	ICR Reference No: 201704-1660-001
Status: Active	Previous ICR Reference No: 201310-1660-003
Agency/Subagency: DHS/FEMA	Agency Tracking No:
Title: National Flood Insurance Program Claims Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/31/2017
	Date Received in OIRA: 04/28/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2020	36 Months From Approved	07/31/2017
Responses	49,423	0	97,242
Time Burden (Hours)	31,633	0	72,548
Cost Burden (Dollars)	0	0	0

---

Abstract: The Claims Forms used for the National Flood Insurance Program are used by policyholders and adjusters to collect the information needed to investigate, document, evaluate, and settle claims against National Flood Insurance Program policies for flood damage to their insured property or qualification for benefits under Increased Cost of Compliance coverage.

---

Authorizing Statute(s): US Code: 42 USC 4001 Name of Law: The National Flood Insurance Act of 1968
   US Code: 42 USC 4102a Name of Law: National Flood Insurance
   EO: EO 1361 Name/Subject of EO: The National Flood Insurance Act of 1968
   PL: Pub.L. 108 - 264 205 Name of Law: The Bunning-Bereuter-Blumenauer Flood Insurance Reform Act (FIRA) of 2004
   PL: Pub.L. 90 - 448 1301 Name of Law: The Housing ans Urban Development Act of 1968
   PL: Pub.L. 93 - 234 2 Name of Law: The Flood Disaster Protection Act of 1973
   EO: EO 44 Name/Subject of EO: CFR 62.20 Claims Appeals
   PL: Pub.L. 103 - 325 555 Name of Law: National Flood Insurance Reform Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 4372	01/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 15231	03/27/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 16

IC Title	Form No.	Form Name
Worksheet - Building	086-0-07	Building - Worksheet
Increase of Compliance Proof of Loss	086-0-10	Increase Of Compliance Proof of Loss
Notice of Loss	086-0-11	Notice of Loss
National Flood Insurance Program Preliminary Report	086-0-13	National Flood Insurance Program Preliminary Report
National Flood Insurance Program Narrative Report	086-0-15	National Flood Insurance Program Narrative Report
National Flood Insurance Program Final Report	086-0-14	National Flood Insurance Program Final Report
Worksheet - Building (Continued)	086-0-08	NFIP Worksheet Building
Cause of Loss and Subrogation Report	086-0-16	Cause of Loss and Subrogation Report
Adjuster Preliminary Damage Assessment	086-0-20	Adjuster Preliminary Damage Assessment
Proof of Loss	086-0-9	Proof of Loss
Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued)	086-0-18	Manufactured (Mobile) Home/Travel Trailer Worksheet (Continued)
Increased Cost of Compliance (ICC) Adjuster Report	086-0-19	Increased Cost of Compliance (ICC) Adjuster Report
Manufactured (Mobile) Home/Travel Trailer Worksheet	086-0-17	Manufactured (Mobile) Home/Travel Trailer Worksheet
National Flood Insurance Program Worksheet - Contents - Personal Property	086-0-06	National Flood Insurance Program Worksheet - Contents - Personal Property
Adjuster Certification Application	086-0-21	Adjuster Certification Application
NFIP Claims Appeal
Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy	086-0-12	Statement as to Full Cost of Repair or Replacement under the Replacement Cost Coverage, Subject to the Terms and Conditions of this Policy

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	49,423	97,242	0	-47,819	0	0
Annual Time Burden (Hours)	31,633	72,548	0	-40,915	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: The NFIP DSA had decrease from 965,000 policies in 2012 to a total of 639,054 policies today (2016). As part of the NFIP Transformation, several forms that the policyholders sees and is required to complete, with the assistance of an adjuster, have been simplified for easier use, thereby decreasing the number of hours to complete. Additionally, with the last filing of the collection in 2013, that was based upon numbers of claims in the post-Superstorm Sandy environment and the number of overall claims has greatly decreased since that time.

---

Annual Cost to Federal Government: $4,001,532

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/28/2017

---