FF 086-0-1 F-050 Flood Insurance Application

U.S. DEPARTMENT OF HOMELAND SECURITY | FEDERAL EMERGENCY MANAGEMENT AGENCY

National Flood Insurance Program
FLOOD INSURANCE APPLICATION, PAGE 1 (OF 2)
O.M.B. No. xxxx-xxxx Expires xxxxx xx, 20xx

We may void your flood insurance policy and deny any claims under that policy if you
or your agent conceal or misrepresent any material fact or circumstance, engage in
fraudulent conduct, or make false statements when completing this application.

NEW

2ND MORTGAGEE/
OTHER

AGENCY NO.:
AGENT NO.:

COMMUNITY
INFORMATION

PHONE NO.:
EMAIL ADDRESS:

TRANSFER (NFIP POLICIES ONLY)

/
/
/
/
POLICY PERIOD IS FROM
TO
WAITING PERIOD:
 STANDARD 30-DAY (12:01 A.M. LOCAL TIME)
MAP REVISION — 1-DAY (12:01 A.M. LOCAL TIME, THE NEXT CALENDAR DAY)
 LOAN TRANSACTION — NO WAITING PERIOD (EFFECTIVE AT TIME OF LOAN CLOSING)
POST-WILDFIRE — 1-DAY (12:01 A.M. LOCAL TIME, THE NEXT CALENDAR DAY)
TRANSFER (NFIP POLICIES ONLY) — NO WAITING PERIOD (12:01 A.M. LOCAL TIME)
NAME AND MAILING ADDRESS OF:

2ND MORTGAGEE

LOSS PAYEE

OTHER

IF OTHER, SPECIFY:

LOAN NO.:
CURRENT MAP INFORMATION
CURRENT COMMUNITY NO./PANEL NO. AND SUFFIX:
CURRENT FIRM ZONE:
/
/
MAP DATE:
COMMUNITY PROGRAM TYPE IS:

REGULAR

–

EMERGENCY

NOTE: ONE BUILDING PER POLICY
IS THE PROPERTY LOCATION THE SAME AS THE POLICYHOLDER MAILING ADDRESS?
YES
NO (IF NO, ENTER PROPERTY ADDRESS AND TYPE.)

PHONE NO.:
EMAIL ADDRESS:
IS THE POLICYHOLDER A TENANT?
YES
NO
YES
IS THE POLICYHOLDER A CONDOMINIUM ASSOCIATION?
YES
NO
IS THE POLICYHOLDER A SMALL BUSINESS?
YES
NO
IS THE POLICYHOLDER A NON-PROFIT ENTITY?
YES
NO
IS THE POLICY FORCE-PLACED BY A LENDER?

NO

NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:

LOAN NO.:
1. BUILDING OCCUPANCY (CHECK ONE)
SINGLE-FAMILY HOME
RESIDENTIAL MANUFACTURED/
MOBILE HOME
RESIDENTIAL UNIT
TWO-TO-FOUR FAMILY BUILDING
OTHER RESIDENTIAL BUILDING
RESIDENTIAL CONDOMINIUM BUILDING
NON-RESIDENTIAL BUILDING
NON-RESIDENTIAL MANUFACTURED/
MOBILE BUILDING
NON-RESIDENTIAL UNIT
2. BUILDING DESCRIPTION (CHECK ONE)
Residential
ENTIRE APARTMENT BUILDING
APARTMENT UNIT
ENTIRE COOPERATIVE BUILDING
COOPERATIVE UNIT
DETACHED GUEST HOUSE
MAIN DWELLING
ENTIRE RESIDENTIAL CONDOMINIUM
BUILDING
RESIDENTIAL CONDOMINIUM UNIT
(IN RESIDENTIAL BUILDING)
RESIDENTIAL CONDOMINIUM UNIT
(IN NON-RESIDENTIAL BUILDING)
OTHER DWELLING TYPE:

FEMA Form 086-0-1

Non-Residential
AGRICULTURAL BUILDING
COMMERCIAL
DETACHED GARAGE
GOVERNMENT-OWNED
HOUSE OF WORSHIP
RECREATION BUILDING
STORAGE/TOOL SHED
OTHER NON-RESIDENTIAL TYPE:
3. FOUNDATION TYPE
SLAB ON GRADE (Non-Elevated)
BASEMENT (Non-Elevated)
CRAWLSPACE (Elevated or Non-Elevated
Sub-Grade Crawlspace)
ELEVATED WITHOUT ENCLOSURE ON
POST, PILE, OR PIER
ELEVATED WITH ENCLOSURE ON POST,
PILE, OR PIER
ELEVATED WITH ENCLOSURE NOT ON
POST, PILE, OR PIER (Solid Foundation
Walls)
IS THE ENCLOSURE/CRAWLSPACE
CONSTRUCTED WITH PROPER FLOOD
OPENINGS OR ENGINEERED OPENINGS?
YES
NO
IF YES, ENTER THE TOTAL NUMBER OF
FLOOD OPENINGS
TOTAL AREA OF ALL PERMANENT OPENINGS:
SQUARE INCHES

BUILDING LOCATION

1ST MORTGAGEE

POLICYHOLDER INFORMATION

NAME(S) AND MAILING ADDRESS OF POLICYHOLDER(S):

BUILDING INFORMATION

POLICY PERIOD

BILLING
AGENT/PRODUCER INFORMATION

NAME AND MAILING ADDRESS OF AGENT/PRODUCER:

LOSS PAYEE
OTHER (AS SPECIFIED IN THE “2ND
MORTGAGEE/OTHER” BOX BELOW)

ENDORSEMENT

PRIOR POLICY #:

IMPORTANT—PLEASE PRINT OR TYPE; ENTER DATES AS MM/DD/YYYY.
FOR RENEWAL, BILL:
POLICYHOLDER
FIRST MORTGAGEE
SECOND MORTGAGEE

RENEWAL

POLICY #:

PROPERTY ADDRESS TYPE:

STREET

OTHER:

FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS
OR EXTENSIONS, DESCRIBE THE INSURED BUILDING:
LATITUDE AND LONGITUDE (OPTIONAL): DATUM:
WGS84
LONGITUDE:
LATITUDE:

NAD83

IS BUILDING LOCATED IN A CBRS SYSTEM UNIT OR OPA?
SYSTEM UNIT
OPA
NO
1982
1990
YEAR SYSTEM UNIT OR OPA ADDED TO CBRS:
IF IN BUFFER ZONE, DID USFWS ISSUE AN OFFICIAL DETERMINATION SHOWING BUILDING
YES
NO
OUTSIDE SYSTEM UNIT OR OPA?
IF IN OPA, IS BUILDING USE CONSISTENT WITH PROTECTED AREA PURPOSE?
YES
NO

TOTAL ENCLOSED AREA:
SQUARE FEET
4. FIRST FLOOR HEIGHT DETERMINATION
ELEVATION CERTIFICATE (OPTIONAL):
ELEVATION CERTIFICATE DATE:
/
/
BUILDING DIAGRAM NUMBER:
If Using Section C:
LOWEST ADJACENT GRADE (IN FEET):
LOWEST FLOOR ELEVATION (IN FEET):
FIRST FLOOR HEIGHT (IN FEET):
If Using Section E:
FIRST FLOOR HEIGHT (IN FEET):
FIRST FLOOR HEIGHT USED (IN FEET):

IS THE BUILDING OVER WATER?
NO
PARTIALLY
ENTIRELY
IS THE BUILDING PROPERLY
FLOODPROOFED?
YES
NO
IS THE BUILDING ELIGIBLE FOR THE
MACHINERY AND EQUIPMENT MITIGATION
YES
NO
DISCOUNT?
BUILDING SQUARE FOOTAGE:
NUMBER OF DETACHED STRUCTURES ON
PROPERTY:
NUMBER OF ELEVATORS:
NUMBER OF FLOORS IN BUILDING
(EXCLUDING BASEMENT/ENCLOSED AREA,
IF ANY):
IF THE COVERAGE IS FOR A UNIT, INDICATE
THE FLOOR WHERE THE UNIT IS LOCATED:

METHOD USED TO DETERMINE FIRST FLOOR
HEIGHT:

TOTAL NUMBER OF UNITS IN THE BUILDING:

5. BUILDING CHARACTERISTICS
IS BUILDING UNDER CONSTRUCTION?
YES
NO
DATE OF CONSTRUCTION:
/
/
HAS THE BUILDING BEEN SUBSTANTIALLY
IMPROVED?
YES
NO
IF YES, ENTER SUBSTANTIALLY IMPROVED
DATE:
/
/
CONSTRUCTION TYPE:
FRAME
MASONRY
OTHER:

BUILDING REPLACEMENT COST (INCLUDING
FOUNDATION): $
IS THE BUILDING A RENTAL PROPERTY?
YES
NO
IS BUILDING THE POLICYHOLDER’S PRIMARY
RESIDENCE?
YES
NO
IF MANUFACTURED/MOBILE HOME OR
BUILDING (INCLUDING TRAVEL TRAILER)
PROVIDE IDENTIFICATION NUMBER:

N
F
I
P
C
O
P
Y

F-050 (XXX 20XX)

U.S. DEPARTMENT OF HOMELAND SECURITY | FEDERAL EMERGENCY MANAGEMENT AGENCY

National Flood Insurance Program
FLOOD INSURANCE APPLICATION, PAGE 2 (OF 2)

NEW

COVERAGE, DEDUCTIBLES,
AND DISCOUNTS

TRANSFER (NFIP POLICIES ONLY)

DISCOUNTS
General Property

Amount of Insurance:
Building $

Contents $

Deductible:
Building $

Contents $

Rate Category:

ENDORSEMENT

PRIOR POLICY #:

COVERAGES AND DEDUCTIBLES
Dwelling

RENEWAL

POLICY #:

IMPORTANT—PLEASE PRINT OR TYPE; ENTER DATES AS MM/DD/YYYY.

SFIP Form:

O.M.B. No. xxxx-xxxx Expires xxxxx xx, 20xx

Rating Engine

Did the applicant have a prior NFIP policy for the building that received
a Newly Mapped discount and lapsed?
Yes
No

RCBAP

If yes, did the lapse occur for a valid reason?

Yes

Is the property eligible for the Newly Mapped discount?

No
Yes

No

Did the applicant have a prior NFIP policy for the building that received
a Pre-FIRM discount and lapsed?
Yes
No

Provisional Rate

If yes, did the lapse occur for a valid reason?

Yes

No

SIGNATURE

I declare under penalty of perjury that the foregoing is true and correct.
/

/

/

/

SIGNATURE OF INSURANCE AGENT/PRODUCER

DATE (MM/DD/YYYY)

SIGNATURE OF POLICYHOLDER (OPTIONAL)

DATE (MM/DD/YYYY)

ADDITIONAL INFORMATION

TOTAL AMOUNT DUE

COMPONENTS OF THE TOTAL AMOUNT DUE
Building Premium

+

$

Contents Premium

+

$

Increased Cost of Compliance (ICC) Premium

+

$

Mitigation Discount

−

$

Community Rating System Discount

−

$

FULL RISK PREMIUM

=

$

Annual Increase Cap

−

$

Pre-FIRM Discount

−

$

Newly Mapped Discount

−

$

Other Statutory Discounts

−

$

ADJUSTED PREMIUM

=

$

Reserve Fund Assessment

+

$

HFIAA Surcharge

+

$

Federal Policy Fee

+

$

Probation Surcharge

+

$

TOTAL AMOUNT DUE

=

$

STATUTORY DISCOUNTS

N
F
I
P
C
O
P
Y

Enter any additional information:

FEMA Form 086-0-1

F-050 (XXX 20XX)

U.S. DEPARTMENT OF HOMELAND SECURITY | FEDERAL EMERGENCY MANAGEMENT AGENCY

National Flood Insurance Program

FLOOD INSURANCE APPLICATION
FEMA FORM 086-0-1
NONDISCRIMINATION

No person or organization shall be excluded from participation in, denied the benefits of, or subjected
to discrimination under the Program authorized by the National Flood Insurance Act of 1968, on the
grounds of race, color, creed, sex, age, or national origin.
PRIVACY ACT NOTICE

Authority: 42 U.S.C. 4011 et seq. authorizes the collection of this information.
Purpose: FEMA will use this information to issue flood insurance policies provided through the National
Flood Insurance Program.
Routine Uses: The information requested on this form may be shared externally as a “routine use” to
other federal agencies, state governments, local governments, tribal governments, certain non-profit
entities, private insurance companies participating in the Write Your Own Program, and their contractors
to implement the National Flood Insurance Act of 1968. A complete list of the routine uses can be found
in the system of records notice associated with this form, “DHS/FEMA-003 National Flood Insurance
Program Files” (79 FR 28747). The Department’s full list of system of records notices can be found on
the Department’s website at http://www.dhs.gov/system-records-notices-sorns.
Disclosure: Furnishing this information is voluntary. However, failure to furnish the requested information
may delay or prevent the issuance of a flood insurance policy.
PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this form is estimated to average 8 minutes 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 the form. This collection of information
is required to obtain or retain benefits. You are not required to submit to this collection of information
unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden
estimate and any suggestions for reducing the burden to: Information Collections Management,
Department of Homeland Security, Federal Emergency Management Agency (FEMA), 500 C Street
SW, Washington, DC 20472, NOTE: Do not send your completed form to this address.