Form 086-0-11 Notice of Loss

DEPARTMENT OF HOMELAND SECURITY

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

NOTICE OF LOSS
NAME(S) OF INSURED:
ADDRESS OF INSURED PROPERTY
Street Address:
City:

State:

POLICY NUMBER:

POLICY PERIOD: From

PROPERTY COVERED

AMOUNT OF INSURANCE

To

PROPERTY DESCRIPTION

BUILDING:

On the

$

Family
Yes

Basement/crawl space?
CONTENTS:

Story Building of

Construction.

No

On the contents in the Building described above
Or in the

$

Family

Story Building of

Yes

Basement/crawl space?

DATE OF LOSS:
Buildings

Construction.

No

FLOOD LOSS:

IMPACT OF LOSS:
LOSS

Zip Code:

Yes

No

BRIEF DESCRIPTION OF DAMAGE
(If emergency handling required, explain why)

Contents

ESTIMATE OF FLOOD LOSS: $
LOCATION OF PROPERTY IF MOVED FOR PROTECTION
Street Address:

DRAFT

City:

INTEREST

State:

Zip Code:

OTHER INSURANCE:
Company:

Type:

Building

Covers:

CONTACT

LOSS PAYEE(S):

MORTGAGEE(S):

Contents

Policy Number:

Covers Flood?

Yes

Name of Primary Contact:

Name of Secondary Contact:

Best Contact Number:

Best Contact Number:

Alternate Contact Number:

Alternate Contact Number:

Best time to Contact:

Best time to Contact

Primary E-mail Address:

Primary E-mail Address

Alternate E-mail Address:

Alternate E-mail Address

No

Mailing/Temporary Address:
City:

State:

FICO Number:

Date:

ADJUSTER

Adjuster To Whom this Notice Has Been Forwarded

Adjuster Handling Other Insurance Loss

Name:

Name:

Address:

Address:

City:
Best Contact Number:

Zip Code:

State:

ZIP:

City:

State:

ZIP:

Best Contact Number:
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

Page 2 of 2