FF 086-0-3 General Change Endorsement

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

National Flood Insurance Program
FLOOD INSURANCE GENERAL CHANGE ENDORSEMENT
FOR ALL POLICY TYPES.
IMPORTANT: Complete this General Change Endorsement form and attach an updated copy of the
Flood Insurance Application Form (FEMA Form 086-0-1) reflecting the changes to the policy.

O.M.B. No. 1660-0006 | Expires XXXX XX, 20XX
POLICY #:

TYPE OF CHANGE

REASON FOR CHANGE

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

REASON FOR CHANGE (CHECK ALL THAT APPLY)
BILLING

MORTGAGEE

POLICY FORM

AGENT/PRODUCER

COMMUNITY INFORMATION

CONSTRUCTION COMPLETED

POLICYHOLDER INFORMATION

PROPERTY ADDRESS (CORRECTION)

STATUTORY DISCOUNTS
RATE CATEGORY
OTHER (SPECIFY):

MAILING ADDRESS

BUILDING INFORMATION

ASSIGNMENT

COVERAGE/DEDUCTIBLE

TYPE OF CHANGE (CHECK ALL THAT APPLY)
OTHER (SPECIFY):

PREMIUM CHANGE continued

NON-PREMIUM CHANGE
PREMIUM CHANGE

COVERAGE/DEDUCTIBLE CHANGE

RATING ADJUSTMENT

RATE CATEGORY CHANGE

RATING CORRECTION

ADDING AN ELEVATION CERTIFICATE

WAITING PERIOD

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)

NONE — RATING CHANGE OR NON-PREMIUM CHANGE
ENDORSEMENT EFFECTIVE DATE:

/

N
F
I
P

/

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)

SIGNATURE OF ASSIGNEE (FOR ASSIGNMENT ONLY)

/
/
DATE (MM/DD/YYYY)

C
O
P
Y

COMPONENTS OF THE TOTAL AMOUNT DUE

AMOUNT DUE

PRIOR ANNUAL COST
UPDATED ANNUAL COST

+

PRO-RATA FACTOR
TOTAL AMOUNT DUE

FEMA Form 086-0-3

$
$
$
(+/−)

$

F-051 (XXX 20XX)

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

National Flood Insurance Program

FLOOD INSURANCE GENERAL CHANGE ENDORSEMENT
FEMA FORM 086-0-3
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
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 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.