086-0-14 National Flood Insurance Program Final Report

National Flood Insurance Program Claims Forms

FEMA FORM 086-0-14 Draft version 12-12-2016

OMB: 1660-0005

Document [pdf]
Download: pdf | pdf
DEPARTMENT OF HOMELAND SECURITY

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

ADJUSTER'S FINAL REPORT

NOTE: The NFIP requires that a preliminary report be received within 15 days of assignment,
and an interim or final report not later than every 30 days thereafter.
NAME(S) OF INSURED:

POLICY NUMBER:

Property Address:

Date of Loss:

City:

State:

Adjuster's File Number:

ZIP:

Adjusting Company
Date of original construction:
Date of
Alteration

Insured at premises since:

Brief Description
of Alteration

Market Value

Cost of
Alteration

Type of Alteration
Repair

Substantial
Improvement*
Yes

No

Yes

No

Yes

No

Reconstruction
Improvement

Repair
Reconstruction

PREMISES HISTORY

Improvement

DRAFT

Repair
Reconstruction
Improvement

* Defined as any repair, reconstruction, or improvement; the cost of which equals or exceeds 50% of the market value of the structure
before the damage occurred or the reconstruction or improvement was begun.
Prior losses (approximate dates and amounts of loss):
Date of Loss

Amount of Loss

Repairs completed

Insured?

Insured but no claim made?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

(Continue on Attachment if additional space is needed for alteration or prior losses.)

INTEREST

Mortgagee(s):
Loss Payee(s):
Other Insurance: Company:
Policy Number:

Type:
Covers:

Building

Contents

Covers Flood?

Yes

No

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

Page 1 of 3

Policy Number:

Property Address:
City:

State:
Duration building will not be habitable:

Date of Loss:

ZIP:
3-7 days

0-2 days

2-4 weeks

Building

CLAIM RECAPITULATION
(See worksheet for details)

Main*

1-2 months

more than 2 months

Contents

Detached Garage

Main*

TOTALS

Property Value (RCV)
Property Value (ACV)

CLAIM SUMMARY

Covered Damage (RCV)
Less Depreciation
Covered Damage (ACV)
Removal/Protection
Net Covered Damage (ACV)
Less Salvage
Less Deductible
Less Excess Over Stated Limit(s)
Claim Payable (ACV)
Damage from Other Cause
Identify all causes of loss:
Does Replacement Cost Coverage (RCC) apply?

Main building RCV: $

DRAFT
If yes, R/C claim: $

EXCLUDED DAMAGES

*Includes manufactured (mobile) home

Approximate Value of Property Excluded

Excluded Building
Damages:

Excluded Contents
Damages:

Yes

No

Total building claim: $

Approximate Damage of Property Excluded

Less than $1,000

$5,000-9,999

Less than $1,000

$5,000-9,999

$1,000-1,999

$10,000-19,999

$1,000-1,999

$10,000-19,999

$2,000-4,999

More than $20,000

$2,000-4,999

More than $20,000

Less than $1,000

$5,000-9,999

Less than $1,000

$5,000-9,999

$1,000-1,999

$10,000-19,999

$1,000-1,999

$10,000-19,999

$2,000-4,999

More than $20,000

$2,000-4,999

More than $20,000

ATTS.

Attachments (enter number of each inside parentheses)
Building worksheets

(

)

Photographs (

)

Proof of loss

Other

Contents worksheets (

)

Narrative

pages)

R/C Proof

Other

(

INSURANCE

The above statements are true and correct to the best of my knowledge. I understand that any false statements may be punishable by
fine or imprisonment under 18 U.S. Code Sec. 1001.
State of:

Insured:

County of:

Insured:

Sworn before me this

Date:

day of

, 20

Witness:

Adjuster's Signature:
Flood Control Number:

FEMA FORM 000-0-0 (05/15)

Page 2 of 3

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 3 of 3


File Typeapplication/pdf
File TitleFEMA Form
File Modified2017-04-12
File Created2016-12-12

© 2024 OMB.report | Privacy Policy