Fema Form 086-0-1 - Flood Insurance Application - 2016 Page 2
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3U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
O.M.B. No. 1660-0006 Expires November 30, 2016
National Flood Insurance Program
FLOOD INSURANCE APPLICATION, PART 2 (OF 2)
ALL DATA PROVIDED BY THE INSURED OR OBTAINED FROM THE ELEVATION
NEW
RENEWAL
TRANSFER (NFIP ONLY)
CERTIFICATE SHOULD BE REVIEWED AND TRANSCRIBED BELOW. THIS PART OF
THE APPLICATION MUST BE COMPLETED FOR ALL BUILDINGS.
PRIOR POLICY #:
SECTION I – ALL BUILDING TYPES
1. Building Use:
f) Does the garage have more than 20 linear feet of finished interior wall,
paneling, etc.?
YES
NO
Main house/building
Detached guest house
Detached garage
Agricultural building
Warehouse
Tool/storage shed
3. Basement/Subgrade Crawlspace
Poolhouse, clubhouse, recreation building
a) Is the basement/subgrade crawlspace floor below grade on all sides?
Other:
YES
NO
2. Garage
b) If yes, does the basement/subgrade crawlspace contain machinery and/or
a) Is there a garage attached to or part of the building?
equipment?
YES
NO
YES
NO
If yes, check the applicable items:
If the answer to 2a is YES, answer 2b through 2f.
Furnace
Heat pump
Air conditioner
Water heater
Fuel tank
Cistern
b) Total area of the garage:
square feet.
Elevator equipment
Washer & dryer
Food freezer
c) Are there any openings (excluding doors) that are designed to allow the
Other machinery and/or equipment servicing the building (describe):
passage of floodwaters through the garage?
YES
NO
If yes, number of permanent flood openings within 1 foot
4. Additions and Extensions (if Applicable)
above the adjacent grade:
. Total area of all permanent
openings:
square inches.
Coverage is for:
d) Is the garage used solely for parking of vehicles, building
Building including addition(s) and extension(s)
access, and/or storage?
YES
NO
Bu ilding excluding addition(s) and extension(s)
e) Does the garage contain machinery and/or equipment?
YES
NO
Provide policy number for addition or extension:
If yes, check the applicable items:
Addition or extension only (include description in the Property Location
Furnace
Heat pump
Air conditioner
box in Part 1)
Water heater
Fuel tank
Cistern
Provide policy number for building excluding addition(s) or extension(s):
Elevator equipment
Washer & dryer
Food freezer
Other machinery and/or equipment servicing the building (describe):
SECTION II – ELEVATED BUILDINGS
(Including Manufactured [Mobile] Homes/Travel Trailers)
1. Elevating Foundation Type
Solid wood frame walls (non-breakaway)
Piers, posts, or piles
Masonry walls (if breakaway, submit certification documentation)
Reinforced masonry piers or concrete piers or columns
Masonry walls (non-breakaway)
Reinforced concrete shear walls
Other (describe):
S olid foundation walls (Note: Not approved for elevating in
d) If enclosed with a material other than insect screening or light wood
Zones V1–V30, VE, or V.)
lattice, provide size of enclosed area:
square feet.
2. Machinery and Equipment Below the Elevated Floor
e) Is the enclosed area used for any purpose other than solely for parking
of
Does the area below the elevated floor contain machinery
and/or equipment?
YES
NO
vehicles, building access, and/or storage?
YES
NO
If yes, check the applicable items:
If yes, describe:
Furnace
Heat pump
Air conditioner
Water heater
Fuel tank
Cistern
Elevator equipment
Washer & dryer
Food freezer
f) Does the enclosed area have more than 20 linear feet of
Other machinery and/or equipment servicing the building (describe):
finished interior wall, paneling, etc.?
YES
NO
4. Flood Openings
3. Area Below the Elevated Floor
a) Is the enclosed area/crawlspace constructed with openings
a) Is the area below the elevated floor enclosed?
YES
NO
(excluding doors) to allow the passage of floodwaters through the
If yes, check one of the following:
Fully
Partially
enclosed area?
YES
NO
b) Does the area below the elevated floor contain elevators?
If yes, indicate number of permanent flood openings within 1 foot
YES
NO
If yes, how many?
above adjacent grade:
.
If the answer to 3a or 3b is YES, answer 3c through 4b.
Total area of all permanent flood openings:
c) Indicate material used for enclosure:
square inches.
Insect screening
b) Are flood openings engineered?
Light wood lattice
Solid wood frame walls (if breakaway, submit certification documentation)
YES
NO If yes, submit certification.
SECTION III – MANUFACTURED (MOBILE) HOMES/TRAVEL TRAILERS
(Wheels must be removed for travel trailer to be insurable.)
1. Manufactured (Mobile) Home/Travel Trailer Data
2. Anchoring
The manufactured (mobile) home/travel trailer anchoring
Year of manufacture:
system utilizes: (Check all that apply.)
Over-the-top ties
Ground anchors
Make:
Frame ties
Slab anchors
Model number:
Frame connectors
Other (describe):
Serial number:
3. Installation
Dimensions:
×
feet
The manufactured (mobile) home/travel trailer was installed in
accordance with: (Check all that apply.)
Are there any permanent additions and/or extensions?
YES
NO
Manufacturer’s specifications
Local floodplain management standards
If yes, the dimensions are:
×
feet
State and/or local building standards
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 INSURANCE AGENT/PRODUCER
DATE (MM/DD/YYYY)
/
/
SIGNATURE OF INSURED (OPTIONAL)
DATE (MM/DD/YYYY)
Previously FEMA Form 81-16
FEMA Form 086-0-1
F-050 (DEC 2013)
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