Form 086-0-12 Statement as to Full Cost of Repair or Replacement under

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM

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

Statement as to full cost of repair or replacement
under the replacement cost coverage, subject
to the terms and conditions of this policy*
(See reverse side for Privacy Act Statement and Paperwork Burden Disclosure Notice)
Policy No. FL
Agency at

Agent

Insured
Location
Type of property involved in claim
Date of loss
1. Full Amount of Insurance applicable to the property for which claim is presented was...................................$
2. Full Replacement Cost of the said property at the time of the loss was............................................................$
3. The Full cost of Repair or Replacement is.........................................................................................................$
4. Applicable Depreciation is.................................................................................................................................$
5. Actual Cash Value is (Line 3 minus Line 4)......................................................................................................$
6. Less deductibles and/or participation by the insured.........................................................................................$
7. Actual Cash Value Claim is (Line 5 minus Line 6)...........................................................................................$

8. Supplemental Claim, to be filled in accordance with the terms and conditions of the Replacement Cost Coverage within
days from date of loss as shown above, will not exceed..........................................................................$
(This figure will be that portion of the amounts shown on Lines 4 and 6 which is recoverable)

* The Standard Flood Insurance Policy is subject to the National Flood Insurance Act of 1968 and any Acts Amendatory thereof, and
Regulations issued by the Federal Insurance Administration pursuant to such statute(s).

Insured

Adjuster

FEMA Form 086-0-12, OCT 07

REPLACES ALL PREVIOUS EDITIONS.

F-103

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 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 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.
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