Fema Form 086-0-1 - Flood Insurance Application - 2016

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U.S. DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0006 Expires November 30, 2016
FEDERAL EMERGENCY MANAGEMENT AGENCY
National Flood Insurance Program
NEW
RENEWAL
TRANSFER (NFIP ONLY)
FLOOD INSURANCE APPLICATION,
PART 1 (OF 2)
PRIOR POLICY #:
IMPORTANT—PLEASE PRINT OR TYPE; ENTER DATES AS MM/DD/YYYY.
FOR RENEWAL, BILL:
POLICY PERIOD IS FROM
/
/
TO
/
/
INSURED
LOSS PAYEE
12:01 A.M. LOCAL TIME AT THE INSURED PROPERTY LOCATION.
FIRST MORTGAGEE
OTHER (AS SPECIFIED IN THE “2ND
WAITING PERIOD:
STANDARD 30-DAY
MORTGAGEE/OTHER” BOX BELOW)
SECOND MORTGAGEE
REQUIRED FOR LOAN TRANSACTION — NO WAITING PERIOD
MAP REVISION (ZONE CHANGE FROM NON-SFHA TO SFHA) — 1 DAY
NAME AND MAILING ADDRESS OF AGENT/PRODUCER:
TRANSFER (NFIP ONLY) — NO WAITING PERIOD
PROPERTY PURCHASED ON OR AFTER 07/06/2012:
YES
NO
IF YES, INDICATE THE PROPERTY PURCHASE DATE:
/
/
NAME AND MAILING ADDRESS OF INSURED:
AGENCY NO.:
AGENT’S TAX ID:
PHONE NO.:
FAX NO.:
EMAIL ADDRESS:
NOTE: ONE BUILDING PER POLICY — BLANKET COVERAGE NOT PERMITTED.
PHONE NO.:
IS INSURED PROPERTY LOCATION SAME AS INSURED’S MAILING AD
DRESS?
NAME AND MAILING ADDRESS OF FIRST MORTGAGEE:
YES
NO IF NO, ENTER PROPERTY ADDRESS. IF RURAL, ENT
ER LEGAL DESCRIPTION, OR
GEOGRAPHIC LOCATION OF
PROPERTY (DO NOT USE P.O. BOX).
LOAN NO.:
FOR AN ADDRESS WITH MULTIPLE BUILDINGS AND/OR FOR A BUILDING WITH ADDITIONS OR
NAME AND MAILING ADDRESS OF
2ND MORTGAGEE
LOSS PAYEE
OTHER
EXTENSIONS, DESCRIBE THE INSURED BUILDING:
IF OTHER, SPECIFY:
IS INSURANCE REQUIRED FOR DISASTER ASSISTANCE?
YES
NO
IF YES, CHECK THE GOVERNMENT AGENCY:
SBA
FEMA
FHA
OTHER (SPECIFY):
CASE FILE NO.:
LOAN NO.:
RATING MAP INFORMATION
GRANDFATHERING INFORMATION
NAME OF COUNTY/PARISH:
GRANDFATHERED?
YES
NO
IF YES,
BUILT IN COMPLIANCE OR
CONTINUOUS COVERAGE (PROVIDE PRIOR POLICY NUMBER IN BOX ABOVE)
COMMUNITY NO./PANEL NO. AND SUFFIX:
CURRENT COMMUNITY NO./PANEL NO. AND SUFFIX:
FIRM ZONE:
COMMUNITY PROGRAM TYPE IS:
REGULAR
EMERGENCY
CURRENT FIRM ZONE:
CURRENT BFE:
N
BUILDING OCCUPANCY
BASEMENT, ENCLOSURE, CRAWLSPACE
IS BUILDING WALLED AND ROOFED?
YES
NO
NONE
FINISHED BASEMENT/ENCLOSURE
IS BUILDING IN THE COURSE OF CONSTRUCTION?
YES
NO
SINGLE FAMILY
CRAWLSPACE
UNFINISHED BASEMENT/ENCLOSURE
F
IS BUILDING OVER WATER?
NO
PARTIALLY
ENTIRELY
2–4 FAMILY
SUBGRADE CRAWLSPACE
OTHER RESIDENTIAL
IS BUILDING INSURED’S PRINCIPAL/PRIMARY RESIDENCE?
YES
NO
I
NUMBER OF FLOORS IN BUILDING (INCLUDING BASEMENT/
NON-RESIDENTIAL (INCLUDING
IS BUILDING A RENTAL PROPERTY?
YES
NO
ENCLOSED AREA, IF ANY) OR BUILDING TYPE
HOTEL/MOTEL)
IS THE INSURED A TENANT?
YES
NO
P
1
2
3 OR MORE
IF YES, IS THE TENANT REQUESTING BUILDING COVERAGE?
YES
NO
BUILDING PURPOSE
SPLIT LEVEL
TOWNHOUSE/ROWHOUSE (RCBAP LOW-RISE ONLY)
IF YES, SEE NOTICE BELOW.
100% RESIDENTIAL
MANUFACTURED (MOBILE) HOME/TRAVEL TRAILER ON FOUNDATION
IS THE BUILDING A SEVERE REPETITIVE LOSS PROPERTY?
YES
NO
100% NON-RESIDENTIAL
IS COVERAGE FOR A CONDO UNIT?
YES
NO
C
M IXED-USE — SPECIFY PERCENTAGE
DOES THE BUILDING HAVE ANY ADDITIONS OR EXTENSIONS?
YES
NO
IS BUILDING IN A CONDOMINIUM FORM OF OWNERSHIP?
Y
ES
NO
OF RESIDENTIAL USE:
%
(ADDITIONS AND EXTENSIONS MAY BE SEPARATELY INSURED.)
TOTAL NUMBER OF UNITS:
O
IS BUILDING A BUSINESS PROPERTY?
HIGH-RISE
LOW-RISE
IS BUILDING ELEVATED?
YES
NO
YES
NO
P
IF YES, AREA BELOW IS:
FREE OF OBSTRUCTION
WITH OBSTRUCTION
IS BUILDING LOCATED ON FEDERAL LAND?
YES
NO
CONTENTS LOCATED IN*:
CONSTRUCTION DATE:
/
/
IS PERSONAL PROPERTY HOUSEHOLD
Y
BASEMENT/ENCLOSURE
CONTENTS?
YES
NO
CHECK ONE OF THE FOLLOWING:
BASEMENT/ENCLOSURE AND ABOVE
BUILDING PERMIT
SUBSTANTIAL IMPROVEMENT
IF NO, DESCRIBE:
LOWEST FLOOR ONLY ABOVE GROUND LEVEL
CONSTRUCTION
F
OR MANUFACTURED (MOBILE) HOMES/
LOWEST FLOOR ABOVE GROUND LEVEL
TRAVEL TRAILERS LOCATED IN A
FOR MANUFACTURED (MOBILE) HOMES/
AND HIGHER
MOBILE HOME PARK OR SUBDIVISION:
TRAVEL TRAILERS LOCATED OUTSIDE A
ABOVE GROUND LEVEL MORE THAN
*IF SINGLE FAMILY, CONTENTS ARE RATED
CONSTRUCTION DATE OF MOBILE HOME
MOBILE HOME PARK OR SUBDIVISION:
1 FULL FLOOR
PARK OR SUBDIVISION FACILITIES
THROUGHOUT THE BUILDING.
DATE OF PERMANENT PLACEMENT
IS BUILDING POST-FIRM CONSTRUCTION?
BUILDING DIAGRAM NO.:
LOWEST ADJACENT GRADE (LAG):
YES
NO
ELEVATION CERTIFICATION DATE:
/
/
(IF POST-FIRM CONSTRUCTION IN ZONES A,
LOWEST FLOOR ELEVATION:
(–) BASE FLOOD ELEVATION:
(=) DIFFERENCE TO NEAREST FOOT:
(+ OR –)
A1–A30, AE, AO, AH, V, V1–V30, VE, OR IF PRE-
IN ZONES V AND V1–V30 ONLY, DOES BASE FLOOD ELEVATION INCLUDE EFFECTS OF WAVE ACTION?
YES
NO
FIRM CONSTRUCTION IS ELEVATION RATED,
IS BUILDING FLOODPROOFED?
YES
NO (SEE THE NFIP FLOOD INSURANCE MANUAL FOR CERTIFICATION FORM.)
ATTACH ELEVATION CERTIFICATE.)
ESTIMATED BUILDING REPLACEMENT COST
DEDUCTIBLE:
BUILDING $
CONTENTS $
(INCLUDING FOUNDATION): $
DEDUCTIBLE BUYBACK?
YES
NO
ADDI
TIONAL LIMI
TS
BASIC LIMITS
(REGULA
R PROGRAM
ONLY)
DEDUCTIBLE
INSURANCE
TOTAL AMOUNT
AMOUNT OF
ANNUAL
AMOUNT OF
ANNUAL
TOTAL
COVERAGE
OF INSURANCE
INSURANCE
RATE
PREMIUM
INSURANCE
RATE
PREMIUM
PREMIUM REDUCTION/INCREASE
PREMIUM
BUILDING
.00
.00
.00
.00
CONTENTS
.00
.00
.00
.00
ANNUAL SUBTOTAL
$
RATE CATEGORY:
PAYMENT METHOD:
CHECK
CREDIT CARD
MANUAL
SUBMIT FOR RATE
PROVISIONAL RATING
ICC PREMIUM
OTHER:
SUBTOTAL
NOTICE: BUILDING COVERAGE BENEFITS — EXCEPT FOR A RESIDENTIAL CONDOMINIUM BUILDING — ARE NOT AVAILABLE IF OTHER NFIP
CRS PREMIUM DISCOUNT
%
BUILDING COVERAGE HAS BEEN PURCHASED BY THE APPLICANT OR ANY OTHER PARTY FOR THE SAME BUILDING.
SUBTOTAL
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. SEE REVERSE SIDE OF COPIES 2, 3, AND 4.
RESERVE FUND
%
SUBTOTAL
/
/
SIGNATURE OF INSURANCE AGENT/PRODUCER
DATE (MM/DD/YYYY)
PROBATION SURCHARGE
FEDERAL POLICY FEE
/
/
TOTAL AMOUNT DUE
$
SIGNATURE OF INSURED (OPTIONAL)
DATE (MM/DD/YYYY)
FEMA Form 086-0-1
Previously FEMA Form 81-16
F-050 (DEC 2013)
PLEASE SUBMIT TOTAL AMOUNT DUE WITH THE NFIP COPY OF THIS APPLICATION.
IF PAYING BY CHECK OR MONEY ORDER, MAKE PAYABLE TO THE NATIONAL FLOOD INSURANCE PROGRAM.
IMPORTANT — COMPLETE PART 1 AND PART 2 (ON LAST PAGE) BEFORE SENDING APPLICATION TO THE NFIP. — IMPORTANT

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