Form 086-0-17 Manufactured (Mobile) Home/Travel Trailer Worksheet

DEPARTMENT OF HOMELAND SECURITY

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

MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER WORKSHEET
INSURED:

POLICY NUMBER:

LOCATION OF RISK:

DATE OF LOSS:
Year

Manufacturer

Model

Size

Serial Number

Color

No. of Bedrooms

Date of Purchase

New or Used

Was Land Included?

Furniture Included?

Cost

Yes
Type of Foundation

No

Yes

Number of Axels

No

Type of Tie-Down

Are Wheels on Unit
Yes

Repairs Agreed
Yes

No

R/C Repair Amount

Salvage Value

Salvor Name

Building Coverage

Content Coverage

Does it cover flood?

No

Other Insurance Carrier:
Policy Number

Yes

No

DRAFT

Value New
Depreciation
Value Used

Addn/Options R/C

Total R/C

Depreciation

Depreciation

Addn/Options A/C

Total ACV

Dwelling Form - Section VII, V., 3., Special Loss Settlement applies to a single family dwelling that is a manufactured
or mobile home or travel trailer, which is at least 16 feet wide and has an area of at least 600 square feet within its
perimeter walls, which is owner occupied, on a principal basis, and insured to value.
Special Loss Calculation
Mobile Home Used Book Value $

x 1.5 =

Replacement Cost Value of Actions, and or Options
Maximum Amount Payable

+
$

(Draw building diagram and dimensions of rooms below, and indicate location of tie downs)

Adjuster:

Examiner:

See Page 2 for Privacy Act Statement and Paperwork Burden Disclosure Notice
FEMA FORM 000-0-0 (05/15)

Page 1 of 2

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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