086-0-10 Increase Of Compliance Proof of Loss

DEPARTMENT OF HOMELAND SECURITY

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

INCREASED COST OF COMPLIANCE PROOF OF LOSS
POLICY NUMBER

POLICY TERM

AGENT

AGENCY AT

AMOUNT OF BLDG. AT TIME OF LOSS
DATE OF LOSS

TO THE NATIONAL FLOOD INSURANCE PROGRAM:
At time of loss, by above indicated policy of insurance, you insured the interest of

against loss by flood to the property described according to the terms and conditions of said policy and of all forms, endorsements, transfers
and assignments attached thereto.
TIME AND ORIGIN

An increased cost of compliance claim was filed on

. The mitigation

option selected was
OCCUPANCY

The described building was occupied at the time of the flood loss as follows, and for no other purpose whatever as:

INTEREST

No other person or persons had any interest therein or encumbrance thereon except

1. FULL AMOUNT OF ICC INSURANCE application to the property for which claim is presented is

$

2. REPLACEMENT COST VALUE of building structure

$

3. ACTUAL CASH VALUE of building structure

$

4. FULL COST OF COMPLIANCE not limited to the amount of ICC coverage

$

5. AMOUNT PAID under Coverage A

$

DRAFT

$

6. AMOUNT PAID under the ICC Coverage D (excluding salvage and subrogation)

The said loss did not originate by any act, design or procurement on the part of your insured, nothing has been done by or with the privity or
consent of insured to violate the conditions of the policy, or render it void; no articles are mentioned herein or in annexed schedules but such
as were destroyed or damaged at the time of said loss, no property saved has in any manner been concealed, and no attempt to deceive the
said insurer as to the extent of said loss, has in any manner been made. Any other information that may be required will be furnished and
considered a part of this proof.
I understand that this insurance (policy) is issued Pursuant to the National Flood Insurance Act of 1968, or Any Act
Amendatory thereof, and Applicable Federal Regulations in Title 44 of the Code of Federal Regulations, Subchapter B, and that
knowingly and willfully making any false answers or misrepresentations of fact may be punishable by fine of imprisonment under
applicable United State Codes.
Subrogation - To the extent of the payment made or advanced under this policy; the insured hereby assigns, transfers and sets over the
insurer all rights, claims or interest that he has against any person, firm or corporation liable for the loss or damage to the property for which
payment is made or advanced. He also hereby authorizes the insurer to sue any such third party in his name.
The insured hereby warrants that no release has been given or will be given or settlement or compromise made or agreed upon with any third
party who may be liable in damages to the insured with respect to the claim being made herein.
The furnishing of this blank or the preparation of proofs by a representative of the above insurer is not a waiver of any of its rights.
Insured
State of
Insured

County of
Subscribed and sworn before me this

day of

, 20
Notary Public

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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