Fema Form 086-0-14 - National Flood Insurance Program Final Report - 2017
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2DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0005
FEDERAL EMERGENCY MANAGEMENT AGENCY
Expires April 30, 2017
NATIONAL FLOOD INSURANCE PROGRAM
THE NFIP REQUIRES THAT A PRELIMINARY REPORT BE RECEIVED WITHIN 15 DAYS OF ASSIGNMENT,
See reverse side for Privacy Act Statement
AND AN INTERIM OR FINAL REPORT NOT LATER THAN EVERY 30 DAYS THEREAFTER.
and Paperwork Burden Disclosure Notice
FINAL REPORT
INSURED
POLICY NUMBER
PROPERTY ADDRESS
DATE OF LOSS
ADJUSTING COMPANY
ADJ. FILE NO.
Insured at premises since:
Date risk was originally constructed:
Date of Alteration
Brief Description of Alteration
Market Value
Cost of Alteration
Type of Alteration
*Substantial Improvement?
Yes
No
Repair
Recon.
Improv.
Yes
No
Repair
Recon.
Improv.
No
Repair
Recon.
Improv.
Yes
* Defined as any repair, reconstruction, or improvement; the cost of which equals or exceeds 50% of the market value of the structure before the damage occurred or the reconstruction
or improvement was begun.
Prior losses (approximate dates and amounts of loss):
Yes
No
Insured?
Yes
No
Insured but no claim made
Repairs completed?
Yes
No
Insured?
Repairs completed?
Yes
No
Insured but no claim made
Insured?
Repairs completed?
Yes
No
Yes
No
Insured but no claim made
(Continue under Remarks if additional space is needed for alteration or prior losses.)
Mortgagee(s):
Loss Payee(s):
No
Yes
Other Insurance:
(Covers flood?)
(Type)
(Company)
(Policy Number)
(Covers Bldg./Conts.)
Duration building will not be habitable:
3-7 days
0-2 days
2-4 weeks
1-2 months
more than 2 months
Claim Recapitulation (See worksheet for details)
Building
Contents
Totals
Covered Damage (ACV)
Removal/Protection
Total Loss (ACV)
Less Salvage
Less Deductible
Excess Over Limit
Claims Payable (ACV)
Identify Cause:
Yes
No
Not applicable
Main building RCV: $
*Includes mobile home.
Total buildiing claim: $
If yes, R/C claim: $
Less than 1,000
5,000 - 10,000
Less than 1,000
Excluded
5,000 - 10,000
Building
1,000 - 2,000
10,000 - 20,000
10,000 - 20,000
1,000 - 2, 000
Damages:
2,000 - 5, 000
2,000 - 5, 000
More than 20,000
More than 20,000
Less than - 1, 000
Excluded
5,000 - 10, 000
Less than - 1, 000
5,000 - 10, 000
Contents
1,000 - 2, 000
10,000 - 20, 000
1,000 - 2, 000
10,000 - 20, 000
Damages:
2,000 - 5, 000
More than 20, 000
2,000 - 5, 000
More than 20, 000
Building worksheets
(
)
Photographs
(
)
Proof of Loss
Other
Narrative (
pp)
Contents worksheets:
(
)
Other
R/C Proof
The above statments are true and correct to the best of knowledge. I understand that any false statements may be punishable by fine or imprisonment under 18 U.S. Code Sec. 1001.
Insured
County of
Insured
State of
Witness
Signed this
day of
, 20
Adjuster's Signature
Adjuster's FC Number
Date of Report
FEMA Form 086-0-14 (04/14)
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