086-0-13 National Flood Insurance Program Preliminary Report

DEPARTMENT OF HOMELAND SECURITY

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

ADJUSTER'S PRELIMINARY REPORT

NOTE: The NFIP requires that a preliminary report be received within 15 days of assignment.
NAME(S) OF INSURED:

POLICY NUMBER:

Property Address:

Date of Loss:

City:

State:

FICO Number:

ZIP:

Mailing/Temporary Address:

Adjuster's File Number:

City:

State:

ZIP:

Tax ID Number:

Best Contact Number:
Alternate Contact Number:

Date Loss Assigned:

Adjusting Company:

Date Insured Contacted:

Adjuster Address:

Date Loss Inspected:

City:
State:
Adjuster's Telephone Numbers:

Zip Code:

Work:

Mobile:

ATTS.

Attachments (enter number of each inside parentheses)
(

)

Photographs (

)

Proof of loss

Other

(specify)

Contents worksheets (

)

Narrative

pages)

R/C Proof

Other

(specify)

Building worksheets

Coverage Verified From:

DRAFT
Program:

Policy Term

NFIP
INSURANCE

(

From:

Agent's Daily

To:

Insured's Policy

Advance payment requested?

No

Single Family

Emergency

General Property

Regular

Dwelling
RCBAP

COVERAGE

Yes

If yes, submit Proof of Loss for (FF 086-0-9) for amount of
payment and supporting documentation with this report.
TYPE OF BUILDING:

SFIP Form:

2-4 Family

DEDUCTIBLE

RESERVE

Building

$

$

$

Contents

$

$

$

Condo Association

Condo Unit

Other Residential

Non-Residential (including Business Buildings and Other Non-Residential Buildings)
Mobile Home/Traveler Trailer:

Make:

Model:
OCCUPANCY:

Owner

RISK

TITLE VERIFIED?

Serial Number:
Tenant

Yes

No

State Government owned

Yes
None

Building elevated?

Yes

Is Risk under construction?

Unfinished

Finished

1

2

3 or more

Yes
Pre-Firm

Basement

First

None

No
Unfinished

Breakaway walls

Finished

PRIOR CONDITION OF:

No
Post-FIRM

Second and/or above
Yes

Is basement flood-proofed?

No Foundation area enclosure?

Date of Construction:
FIRM Date:

Seasonal

No

In case of multiple occupancy, indicate floor(s) occupied by insured:
Type of basement:

Principal

Source of verification:

Number of floors in the building including basement/crawl space:
Is building a split level?

Unoccupied RESIDENCY:

Building

Poor

Fair

Good

Very Good

Contents

Poor

Fair

Good

Very Good

See Page 3 for Privacy Act Statement and Paperwork Burden Disclosure Notice
FEMA FORM 000-0-0 (05/15)

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Policy Number:

Property Address:
City:

State:

Date of Loss:

ZIP:

FOUNDATION STRUCTURE:
PILES:

Wood post

PIERS:

Reinforced concrete

Reinforced block

WALLS:

Reinforced concrete

Block

Concrete slab

RISK CONTINUED

Brick

Steel

Other
Unreinforced block

Unreinforced block

Brick

Other
Treated plywood

Reinforced concrete shear

Other

EXTERIOR WALL STRUCTURE:

EXTERIOR WALL SURFACE TREATMENT:

Reinforced concrete

Concrete block

Steel and glass

Brick and stone

Wood stud

Unfinished
Wood siding

Other

Stone or brick veneer
Metal sheathing/siding
Other

Vinyl sheathing/siding

CONTENTS ARE:

Stucco

CONTENTS LOCATED IN:

Household

Basement

Other than household

First floor and above

First floor

Basement and first floor
Second floor and above

Distance to the insured building:

Nearest body of water to the insured building:

DRAFT

Was there a general and temporary condition of flooding?
No (Explain fully under Remarks)
Cause of loss:

Yes (Indicate cause of loss below)

Tidewater overflow

Stream, river, or lake overflow

Alluvial fan overflow

Accumulation of rainfall or snowmelt
Flood characteristics:

Velocity flow

Low velocity flow or ponding

Yes

ORIGIN

Did other than natural cause contribute to flooding?

Wave action

Was there Erosion?

Yes

No

No

If yes, complete Cause for Loss and Subrogation Report form (FF 086-0-16).
DATE/TIME WATER ENTERED BUILDING:
Date:

Time:

PM

AM

Exterior:

DATE/TIME WATER RECEDED FROM BUILDING:
Date:

Time:

Date:

Hours/

Interior:

PM

AM

LENGTH OF TIME WATER REMAINED IN BUILDING:
Days/

WATER/WAVE HEIGHT IN INCHES:
Main Building - Dwelling or Commercial Building:

Minutes

Detached Garage:
Exterior:

Interior:

Adjuster's Signature:
Flood Control Number:

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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