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pdfDEPARTMENT 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 Type | application/pdf |
| File Title | FEMA Form |
| File Modified | 2017-04-12 |
| File Created | 2016-12-12 |