FEMA Form FF-104-F Flood Insurance Assessment

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

OMB Control No. XXX-XXXX
Expiration Date: XX/XX/XXXX

Hermit’s Peak/Calf Canyon Claims Office

FLOOD INSURANCE ASSESSMENT
CLAIMANT CONTACT INFORMATION
Claim Number:

Name:

Additional Claimant Name (if any):

Current Address:

City, State, Zip and County:

Property Address to be Insured:

City, State, Zip:

Contact Phone Number:

Email (optional):

DRAFT

Please complete a separate form for each building to be insured on the damaged property.

Note: Attaching photos of the front and back of the structure, along with a clear view of the foundation can significantly aid us in
evaluating the claim.
1. Does your building have 2 or more outside rigid walls with a fully secured roof and it is affixed to a permanent foundation?
Yes (continue to question 2)

No (STOP — this building is ineligible for NFIP flood coverage)

2. Did you have flood coverage prior to the Hermit’s Peak Fire (before 4/6/2022)?
Yes

No

If yes, provide insurance company name and policy number:
Were you required to purchase flood insurance?

Yes

No

3. Please specify the building if there is more than 1 building associated with the same address. (For example, Main House, Guest
House, Barn, Garage, Shed, etc.)
4. What county is the above property in:
5.

Do you own this property?

Mora

San Miguel

Other:

Do you rent this property?

6. Identify occupancy type of your building:
Residential Occupancy Types:
Single Family Home (Includes townhouse, rowhouse)
Multi-Family Building (Building with 2 to 4 housing units)
Residential Mobile/Manufactured Home (Must be affixed to a permanent foundation)
Residential Unit (A single family residential unit such as an apartment or condominium unit within a multi-unit residential
building.)
Non-residential Occupancy Types:
Non-residential Building (Includes detached garage, shed, barn, commercial building)
Non-residential Unit (A commercial or non-habitational unit within a non-residential building)
Non-residential Mobile/Manufactured Building (Used for non-residential purposes such as storage, business; must be affixed
to a permanent foundation)
7. If building occupancy type is Single Family Home or 2 to 4 Multi-Family Building, please select the building’s construction type
(Based on the construction used for the wall on the building’s first floor):
Frame

Masonry

Other (please describe):

FEMA Form FF-104-FY-24-116 (3/24)

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8. If building occupancy type is a Unit (residential or non-residential), what floor is your unit on?
9. If building occupancy type is 2 to 4 Family or Other Residential Building, please provide total number of units within the building:
10. If building occupancy type is residential (not including Other Residential Building), please provide the total square footage of the
building (Do not include basement, enclosure, or garage square footage in total):
11. If building occupancy type is Other Residential, or any type of Non-residential building, please provide the replacement cost of
the building (Do not include land value):
12. If building occupancy type is Mobile/Manufactured Home/Building (residential or non-residential, please provide the Mobile/
Manufactured Home ID (serial number):
13. In what year was the building built/manufactured?

DRAFT

14. What type of foundation does your building have?

Slab-on-grade (building sits directly on concrete slab on the ground)

Crawlspace (an area of less than 5 feet between the ground and the lowest floor of the building)
Basement (the lowest floor of the building is below ground on all sides)

Elevated with out Enclosure on Post, Piles or Piers (lowest floor of building is raised above the ground and there are no areas
enclosed below the elevated floor)
Elevated with Enclosure on Post, Piles or Piers (lowest floor of building is raised above the ground more than 5 feet and there
is an enclosed area beneath the elevated floor)
Elevated with Enclosure not on Post, Piles or Piers (lowest floor of building is raised above the ground more than 5 ft on fullstory, solid perimeter walls with an enclosed area beneath the elevated floor)

15. Total Number of floors in your building (not including attic, basement, crawlspace, or enclosed area):
16. Will you live in this residence for more than 50% of the year?
17. Is there a mortgage on your property?

Yes

Yes

No

No

If yes, please provide lender’s name, address, and loan number.

DECLARATION
I hereby certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that any
misrepresentation may result in denial of coverage or other penalties.
Claimant Signature:

FEMA Form FF-104-FY-24-116 (3/24)

Date:

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