Form 086-0-16 Cause of Loss and Subrogation Report

DEPARTMENT OF HOMELAND SECURITY

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

CAUSE OF LOSS AND SUBROGATION REPORT
NAME(S) OF INSURED:

POLICY NUMBER:

COMPLETE ADDRESS OF PROPERTY DAMAGED

CAUSE OF LOSS (Check the box(es) that apply)
1.

IMPROPER DIVERSION OF WATER

7.

NEGLIGENT MAINTENANCE OF SEWER LINES

2.

IMPROPER BUILDING

8.

FAILURE TO USE PUMPS

3.

IMPROPER GRADING

9.

INADEQUATE PUMPS

4.

DEBRIS ACCUMULATION

10.

EXCESSIVE DAM WATER RELEASE

5.

INADEQUATE SEWER LINES

11.

EXCESSIVE WATER RELEASE (Mechanical)

6.

IGNORING FLOODPLAIN MANAGEMENT (Regulations)

12.

ANY OTHER FACTOR THAT IDENTIFIES A
RESPONSIBLE PARTY OR ACT AS THE CAUSE
(Explain; use the space below)

IDENTIFICATION OF RESPONSIBLE PARTY
NAME
COMPLETE ADDRESS

DRAFT

IS THE RESPONSIBLE PARTY INSURED?
Yes

No

(if yes, by whom?)

IDENTIFICATION OF ANY STATUTES OR POLITICAL SUBDIVISION THAT WOULD CONTROL, LIMIT, OR TIME BAR A TORT ACTION
AGAINST THEM (e.g., a local notice of claim against the municipality or county statute that would preclude suit if the notice was not filed on
time - usually a short period of time for filing is provided).

MAKE IMMEDIATE TELEPHONE CONTACT WITH THE NFIP BUREAU AND STATISTICAL AGENT IF EXPIRATION OF TIME IS
IMMINENT.
STATE INVESTIGATION PERFORMED TO DATE

PLEASE ATTACH ANY DIFINITIVE MATERIAL TO THIS REPORT.
WHAT FURTHER INVESTIGATION IS CONTEMPLATED?

HAS INSURED BEEN ADVISED OF SUBROGATION RESPONSIBILITIES?
Yes

No

DOES INSURED HAVE AN ATTORNEY?
Yes

(if yes, by when?)
NAME OF ATTORNEY

No
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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