Form 086-0-9 Proof of Loss

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB Control Number: 1660-0005
Expiration: MM DD, YYYY

PROOF OF LOSS
Filing:

Initial

Additional

Name(s) of Insured:

Policy Number:
Date & Time of Loss:

Address of Insured Property:
City:

State:

Is there a mortgage interest or additional interest
in the property:
No
Yes

ZIP:

If yes, list here:

Mailing Address:
City:

State:

Best Contact Number:

Insurance Agent/Company Representative

ZIP:

Alternate Number:

E-mail Address:
Occupancy:

Best Contact Number
Owner Occupied

Occupancy Type:

Tenant Occupied

Single Family

2-4 Family

Other Residential

Non-Residential Business

Other Non-Residential

Description of flood causing loss (source of flood waters i.e. river, lake, or ocean/gulf):
Other Insurance that may cover any of this loss:

None

Building Coverage

Contents Coverage

Amount of coverage at time of loss:

$

$

Replacement Cost Value (RCV):

$

$

Actual Cash Value (ACV) of Repairs: $

$

Subtract unrecoverable depreciation: $

DRAFT

Subtract Deductible:

$

$

NET AMOUNT CLAIMED

$

$

I have attached specifications of damaged buildings and detailed repair estimates. If claiming damage to contents, I have
attached a detailed inventory of damaged personal property.
I understand that I must file proof of loss or an amended proof
of loss within 60 days of the date of the loss or within any
extension of that deadline made in writing by the Associate

I understand that I may still request additional payment for
other flood damages if I believe that not all damages were
addressed in this estimate.

Administrator for Federal Insurance and Mitigation.
The flood event identified above damaged or destroyed the
property claimed on this Proof of Loss.

In the event a third party is responsible for the damage, I
hereby authorize the insurer to bring suit in my name against
any third party who may be responsible for the damages.

I understand the policy is issued pursuant to the National
Flood Insurance Act of 1968, as amended, and applicable
Federal Regulations in Title 44 of the Code of Federal
Regulations, Subchapter B.

I have not knowingly and willfully falsified or concealed a
material fact, made a false or fraudulent representation, or
presented any false document in connection with this claim,
and acknowledge that any such action is subject to
prosecution under federal law.
I declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct.

Signature of Insured:

Date:

Signature of Insured:

Date:
See Page 2 for Privacy Act Statement and Paperwork Burden Disclosure Notice

FEMA FORM 000-0-0 (05/15)

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PRIVACY ACT STATEMENT
The information requested is necessary to process the subject loss. The authority to collect the information is 42 U.S.C. §§ 4001 to 4130. It is
voluntary on your part to furnish the information. However, omission of an item may preclude processing of the form. The Federal Emergency
Management Agency will not disclose this information, except to: the servicing agent acting as the Federal 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 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.

TITLE

BURDEN HOURS

086-0-06

Worksheet-Contents-Personal Property

2.50 Hours

086-0-07

Worksheet-Building

2.50 Hours

086-0-08

Worksheet-Building (Continued)

1.00 Hours

Proof of Loss

.08 Hours

Increased Cost of Compliance

2.00 Hours

Notice of Loss

.07 Hours

086-0-12

Statement as to Full Cost to Repair or Replacement Cost Coverage,
Subject to the Terms and Conditions of this Policy

.10 Hours

086-0-13

Adjuster's Preliminary Report

.07 Hours

086-0-14

Adjuster's Final Report

.07 Hours

086-0-15

National Flood Insurance Program Narrative Report

.08 Hours

086-0-16

Cause of Loss and Subrogation Report

1.00 Hours

086-0-17

Manufactured (Mobile) Home/Travel Trailer Worksheet

.50 Hours

086-0-18

Mobile Home/Travel Trailer Worksheet (Continued)

.25 Hours

086-0-19

Increased Cost of Compliance (ICC) Adjuster Report

.42 Hours

086-0-20

Adjuster's Preliminary Flood Damage Assessment

.25 Hours

086-0-21

Adjuster's Certification Application

.25 Hours

086-0-09
086-0-10
086-0-11

FEMA FORM 000-0-0 (05/15)

DRAFT

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