FF 086-0-2 Cancellation and Nullification Request Form

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

National Flood Insurance Program

1:54 pm, Oct 08, 2020

Flood Insurance Cancellation/Nullification Request Form
O.M.B. No. 1660-0006 | Expires XXXX XX, 20XX
POLICY #:

POLICYHOLDER INFORMATION

Policy Period is From

To

Cancellation Effective Date:

Agent No.:
Phone No.:

Name and Mailing Address of First Mortgagee:

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FIRST MORTGAGEE INFORMATION

Phone No.:
Email Address:
Property Address if Different from Policyholder’s Mailing Address:

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PROPERTY LOCATION

Agency No.:

Email Address:

Loan No.:

CANCELLATION REASON
CODE
REFUND

Name and Mailing Address of Policyholder for Mailing Refund:

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AGENT/PRODUCER INFORMATION

Agent/Producer Information for the Policy Being Canceled:

SECOND MORTGAGEE / OTHER
INFORMATION

POLICY
PERIOD

IMPORTANT – Please print or type; enter dates as MM/DD/YYYY.

Information Below is That of:

Second Mortgagee

Other (Specify):

Please see all valid cancellation reason codes and requirements for their use in the “How
to Cancel” section of the NFIP Flood Insurance Manual on the FEMA website.
https://www.fema.gov/flood-insurance-manual

Loss Payee

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P
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P
Y

CANCELLATION REASON CODE:

Make Refund Payable To (check one):

Policyholder

Payor

Agent (Reason Code 5 Only)

Mail Refund To (check one):

Policyholder

Payor

Agent (Reason Code 5 or at Request of Policyholder)

SIGNATURE

The above statements are correct to the best of my knowledge. I understand that any false statements may be punishable by fine
and/or imprisonment under applicable federal law.

SIGNATURE OF POLICYHOLDER

SIGNATURE OF AGENT/PRODUCER
FEMA Form 086-0-2

DATE

DATE
REPLACES ALL PREVIOUS EDITIONS.

PLEASE ATTACH ALL REQUIRED DOCUMENTS TO NFIP COPY OF CANCELLATION/ NULLIFICATION REQUEST FORM.
SEND ORIGINAL TO NFIP, KEEP A COPY FOR YOUR RECORDS, AND PROVIDE COPIES TO THE POLICYHOLDER AND MORTGAGEE(S).

F-052 (XXX 20XX)

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

National Flood Insurance Program

FLOOD INSURANCE CANCELLATION/NULLIFICATION REQUEST FORM
FEMA FORM 086-0-2
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

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

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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

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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

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Public reporting burden for this form is estimated to average 6 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.