Form 086-0-21 Adjuster Certification Application

DEPARTMENT OF HOMELAND SECURITY

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

ADJUSTER REGISTRATION APPLICATION
New Registration

Re-registration

Independent Adjuster

WYO In-house adjuster

NFIP-BSA General Adjuster

Public Adjuster
Please complete the below in its entirety. Then turn the form over and complete the remaining applicable parts.
Sign and date the form and mail it to:
NFIP Bureau & Statistical Agent, Certification Coordinator, P.O. Box 310, Lanham, MD 20703-0310
1. NAME (Last, First, MI)

2. FLOOD CONTROL NUMBER (FCN)

3. STREET ADDRESS (include city, state, and zip code)

a. CELL PHONE NO.
b. OFFICE PHONE NO.
c. E-MAIL ADDRESS

4a. Have you ever been issued a license or similar credential to
work as an insurance adjuster? If yes, list the State(s), otherwise
check "no."
Yes
No

4b. Are you currently a State licensed public adjuster? If yes, list the
Yes
No
state(s), otherwise check "no."

5. Number of years of flood adjuster experience

Number of years of property adjuster experience

If yes, which State(s)?

6. If you have received a state adjuster license, has such license been revoked, suspended, limited, or otherwise
subject to discipline? If yes provide reason below.

7. Have you ever attended an NFIP Claims Presentation?

Yes

Yes

No

No

DRAFT

If yes, where and when was your last attended NFIP annual adjuster or emergency adjuster authorization seminar? City

8. Did you attend a company sponsored training session?

Yes

State
Year

No

If you have attended a privately sponsored NFIP annual adjuster seminar indicate the year, location and the name of the private company/
sponsor.
Year:

Location:

Private Company/Sponsor:

9. If you carry your own professional E&O insurance policy, list the carrier, otherwise check "no"
No

Carrier:

Check "Yes" or "No" to indicate the category(s) in which you are seeking registration. Check all which applies under each registration type:
Yes

10. Residential (Dwelling)

No

New Registration

Re-Registration; year of initial registration

N/A

(formerly certification)
11. Manufactured (Mobile) Home/
Traveler Trailer

Yes

No

New Registration

N/A

(formerly certification)

Commercial (General Property)
12. Small Commercial
(up to $100,000)

Re-Registration; year of initial registration

Yes

No

New Registration

Re-Registration; year of initial registration

N/A

(formerly certification)
13. Large Commercial
(from $100,001 to $500,000)

Yes

No

New Registration

Re-Registration; year of initial registration

N/A

(formerly certification)
14. Condominium (RCBAP)

Yes

No

New Registration

Re-Registration; year of initial registration

N/A

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

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For the category(ies) that you have selected, answer the following questions:
15. What is the building dollar limit estimate that you have prepared in this category?
Building $
16. What is the dollar limit on contents inventory that you have prepared?
Contents $
17. What is the largest combined loss and claim that you have adjusted?
Building $

Contents $

Total Amount $

If you have adjusted a condominium loss, provide the name, date of loss, location (complete address), and contact individual, along with
telephone number.

If you are applying for new registration at any level, provide three references who can attest to your knowledge, experience and customer
service skills. If you are applying for new registration at the Large Commercial or RCBAP loss type, provide three letters of recommendation
from an insurance or adjusting firm claim management personnel.
NAME & POSITION

COMPANY

E-MAIL

DRAFT

PHONE NUMBER

NAME & POSITION

COMPANY

E-MAIL
PHONE NUMBER

NAME & POSITION

COMPANY

E-MAIL
PHONE NUMBER

DECLARATION ACKNOWLEDGEMENT.
I declare that I have read of the Standard Flood Insurance Policy form applicable to my registration request, and will to the best of my ability,
handle all received NFIP insured claim assignments in accordance with the terms and conditions of the Standard Flood Insurance Policy, and
within the standards and requirements stated in the NFIP Adjuster Claims Manual.
I also declare that all responses on this application are true and accurate. I acknowledge the misrepresentation of any information provided on
this application, may result in the denial of my registration request, or may result in the revoking of new registration stemming from this
request, if a misrepresentation is discovered after my request has been accepted.

Signature

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

Date

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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 Registration Application

.25 Hours

086-0-09
086-0-10
086-0-11

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

DRAFT

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